A client who is admitted to the intensive care unit (ICU) with acute decompensated heart failure is receiving a continuous infusion of milrinone via a subclavian venous catheter. Which action should the nurse take when preparing to administer the first dose of IV furosemide?

Administer furosemide IV over ten minutes.

Notify the healthcare provider (HCP) of the incompatibility of the two drugs.

Infuse furosemide through a central line to prevent extravasation.

Give furosemide through a separate IV access

Answer and Explanation

The Correct Answer is D

A. Administer furosemide IV over ten minutes. While slow IV administration is recommended to prevent ototoxicity, the priority concern is that milrinone and furosemide are incompatible when administered in the same IV line. The nurse must first ensure separate IV access before considering the administration rate.
B. Notify the healthcare provider (HCP) of the incompatibility of the two drugs. The nurse does not need to notify the HCP but should instead use a separate IV line or flush the line thoroughly before and after administration if only one access is available. Milrinone and furosemide should never be mixed, as their combination can cause precipitation, leading to catheter occlusion or embolization.
C. Infuse furosemide through a central line to prevent extravasation. Furosemide can be given peripherally or centrally, but the concern here is drug incompatibility, not extravasation. Furosemide is not a vesicant, so central line administration is not required unless no peripheral access is available.
D. Give furosemide through a separate IV access. Milrinone is incompatible with furosemide due to pH differences, which can lead to precipitation and potential catheter occlusion. To ensure safe administration, furosemide should be given through a separate IV line or, if no secondary access is available, the line should be flushed thoroughly before and after administration.

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Correct Answer is D

Explanation

A. Observe vital signs sequences as a way of assessing for Cushing's triad. Cushing’s triad (hypertension with widened pulse pressure, bradycardia, and irregular respirations) is a late sign of increased intracranial pressure (ICP). While monitoring for it is important, early recognition and direct ICP monitoring are more effective in preventing deterioration.
B. Evaluate hourly urinary output. Mannitol is an osmotic diuretic that can cause significant diuresis, requiring close monitoring of urine output to prevent dehydration and electrolyte imbalances. However, assessing ICP is the priority because increased ICP can cause brain herniation, which is life-threatening.
C. Monitor arterial blood pressure. Dopamine is a vasopressor used to maintain cerebral perfusion pressure (CPP), which is crucial in head injury management. While blood pressure monitoring is essential, directly assessing ICP ensures that treatment is effective in preventing secondary brain injury.
D. Assess intracranial pressure following intracranial transducer placement. The highest priority is monitoring ICP immediately after placement to detect dangerous elevations that could lead to herniation. The intraventricular catheter provides real-time pressure readings, guiding interventions like mannitol administration and blood pressure control to optimize cerebral perfusion and prevent worsening neurological damage.

A. Turn off the pacemaker. B. Check the sensitivity control. C. Increase the milliamps (mA). D. Position the client on the left side.

Correct Answer is B

Explanation

A. Turn off the pacemaker. Turning off the pacemaker is not appropriate because the client has a third-degree heart block, which means their heart is not conducting impulses properly. Disabling the pacemaker could lead to severe bradycardia or asystole. The goal is to troubleshoot the issue rather than stopping pacing altogether.
B. Check the sensitivity control. Loss of sensing means the pacemaker is not detecting the client's intrinsic heart activity, which can lead to inappropriate pacing or failure to respond to the heart’s natural rhythm. Adjusting the sensitivity setting ensures that the pacemaker can recognize the client's heartbeats and pace appropriately. This is the first step in troubleshooting pacemaker malfunctions related to sensing issues.
C. Increase the milliamps (mA). Increasing the milliamps (mA) is used when there is failure to capture, meaning the pacemaker is delivering impulses but the heart is not responding. Since the problem here is failure to sense, adjusting the sensitivity setting is the correct first action.
D. Position the client on the left side. Repositioning the client is sometimes recommended for displacement of a transvenous pacemaker lead, but in this case, the issue is sensing failure, not lead displacement. Checking and adjusting the pacemaker settings is a more appropriate first step before considering repositioning.

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A client who is admitted to the intensive care unit (ICU) with acute decompensated heart failure is receiving a continuous infusion of milrinone via a subclavian venous catheter. Which action should the nurse take when preparing to administer the first dose of IV furosemide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Correct Answer is B

Explanation

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