A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

Assess pupillary response to light hourly.

Initiate seizure precautions.

Measure urinary output every hour.

Monitor serum potassium frequently.

Answer and Explanation

The Correct Answer is C

A. Assessing pupillary response to light is not directly related to the administration of dopamine for hypotension and does not reflect the immediate effects of the medication on the cardiovascular or renal systems.

B. Seizure precautions are not a standard intervention for a patient receiving dopamine unless the patient has a history of seizures or there is another indication for such precautions.

C. Measuring urinary output every hour is essential as it reflects the patient's fluid balance and kidney function, which can be affected by dopamine administration. It is a direct measure of the effectiveness of the medication in improving renal perfusion and the patient's hemodynamic status.

D. While monitoring serum potassium levels is important in patients receiving IV therapy, it is not the most immediate concern when administering dopamine for hypotension, unless the patient has a known electrolyte imbalance.

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Correct Answer is A

Explanation

A. Determining the patient's need for pain medication is a priority to ensure the patient's comfort during the end-of-life care process. Pain management is a critical aspect of palliative care and should be addressed promptly.
B. Updating the nurse manager on the patient's status is important but is not the immediate priority. The nurse manager's awareness does not directly impact the patient's comfort or care at the moment of impending death.
C. Conveying the patient's status to the chaplain may be part of the holistic care approach and can provide spiritual support to the patient and family, but it is not the first priority in terms of the patient's immediate physical needs.
D. Documenting the impending signs of death is essential for legal and medical records; however, it is secondary to addressing the patient's immediate needs, such as pain relief.

A. A sluggish blood return B. Cool sensation above the site C. Iced streak tracking the vein D. Circumferential skin irritation

Correct Answer is C

Explanation

A. A sluggish blood return: While a sluggish blood return may indicate potential issues with the IV line, it does not require immediate intervention unless accompanied by other signs of
complications.
B. Cool sensation above the site: Cool sensation above the site may indicate impaired circulation, but it is not as concerning as other findings requiring immediate intervention.
C. Iced streak tracking the vein: Correct! An iced streak tracking the vein suggests infiltration of IV fluids into the surrounding tissue, which can cause tissue damage and compromise the
effectiveness of the IV therapy. Immediate intervention is needed to prevent further complications.
D. Circumferential skin irritation: Circumferential skin irritation may indicate an allergic reaction or contact dermatitis, which requires attention but is not as urgent as an infiltration.

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A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

Nursing Test Bank

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