A client who has sustained blunt abdominal trauma is admitted to the ICU. Upon assessment the nurse notices the following vital signs: T-99F; HR- 148: RR-38; B/P-60/40. The client is diaphoretic and restless. The following selections are approved by the ICU physician. What would be the PRIORITY nurse's action?
Auscultate bowel sounds, record the findings and obtain a 12-lead ECG
Initiate the standing prescription for v Dopamine at 16 mcg/kg/minute
Place soft restraints on the upper extremities and sedate as necessary
Lower the head the bed obtain a pulse ox and increase the rate of iv fluids
The Correct Answer is D
A. Auscultate bowel sounds, record the findings, and obtain a 12-lead ECG
While auscultating bowel sounds can help assess for bowel injury and an ECG is useful for monitoring cardiac function, these interventions are not the priority. The client is in shock and requires immediate intervention to restore perfusion.
B. Initiate the standing prescription for Dopamine at 16 mcg/kg/minute
Dopamine can be used to support blood pressure in shock, but fluid resuscitation is the first-line intervention in hypovolemic shock. Vasopressors like dopamine are typically added after fluid resuscitation if hypotension persists.
C. Place soft restraints on the upper extremities and sedate as necessary
The client's restlessness is likely due to hypoxia and inadequate perfusion, not agitation. Restraints and sedation would delay critical interventions and could worsen hemodynamic instability.
D. Lower the head of the bed, obtain a pulse ox, and increase the rate of IV fluids
The client is in hypovolemic shock due to suspected internal bleeding. Lowering the head of the bed improves cerebral perfusion, increasing IV fluids restores intravascular volume, and checking pulse oximetry ensures adequate oxygenation. This is the priority action to stabilize the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
A. Color of conjunctiva
While assessing for signs of perfusion is important, conjunctival color is not a primary assessment for norepinephrine administration. Perfusion is better assessed through blood pressure, heart rate, capillary refill, and urine output.
B. Deep tendon reflexes
Norepinephrine primarily affects vascular tone and cardiac output. Deep tendon reflexes are not a priority assessment for this medication.
C. IV Insertion site
Norepinephrine is a vasopressor, and extravasation can cause severe tissue necrosis. Frequent monitoring of the IV site is necessary to prevent complications.
D. Blood pressure and heart rate
Norepinephrine increases blood pressure and heart rate through vasoconstriction. Continuous monitoring is required to assess for excessive hypertension, tachycardia, or inadequate response to therapy.
E. Hourly urine output
Urine output is an essential indicator of organ perfusion. Since norepinephrine is used to maintain adequate blood pressure and perfusion in septic shock, monitoring urine output helps assess the effectiveness of treatment.
Correct Answer is ["70"]
Explanation
- Formula: Dose = Weight (kg) × 80 units/kg
- 5600 units ÷ 80 units/kg = 70 kg
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