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?

Choice A reason: A 16-year-old client diagnosed with major depression who refuses to participate in group does not require the nurse's immediate attention. Depression is a mood disorder that causes persistent feelings of sadness, hopelessness, and loss of interest. Refusing to participate in group may indicate low motivation, social withdrawal, or poor self-esteem, which are common symptoms of depression. The nurse should respect the client's preference and offer alternative activities or individual therapy.

Choice B reason:This client requires immediate intervention because pacing can be a sign of agitation, restlessness, or escalating mania. Clients with bipolar disorder in a manic phase may exhibit increased energy, impulsivity, irritability, and even aggression. If not addressed promptly, this behavior could escalate to disruptive outbursts, impulsive actions, or even violence toward themselves or others. The nurse should intervene by using calm communication, redirection, and possibly medication if prescribed to help de-escalate the situation and ensure safety.

Choice Creason:This scenario involves peer conflict, which is important to address, but it does not necessarily indicate an immediate risk of harm. Clients with antisocial behavior often engage in conflict due to manipulative or confrontational tendencies, but being yelled at does not mean they are in immediate danger. The nurse should monitor the situation and intervene to prevent escalation, but other safety concerns take priority.

Choice D reason: A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack does not require the nurse's immediate attention. Anorexia nervosa is an eating disorder that causes extreme restriction of food intake and fear of weight gain. Refusing to eat the evening snack may indicate distorted body image, dietary rules, or anxiety, which are common factors of anorexia nervosa. The nurse should encourage the client to eat and provide support and education.

The correct answer is A, B, C, and D.

Choice A reason: Flushing the gastrostomy tube with water is essential to maintain tube patency and prevent medication interactions. It should be done before and after medication administration. The typical amount of water used for flushing can range from 15 to 30 mL.

Choice B reason: Administering each medication separately is a critical practice to prevent drug interactions and ensure that the full dose of each medication is delivered. It also helps in preventing the clogging of the tube.

Choice C reason: Documenting all liquid volumes, including medications and water used for flushing, is important for accurate fluid intake records. This helps in maintaining fluid balance and monitoring the patient’s hydration status.

Choice D reason: Checking gastric residual volume is important to assess the patient’s tolerance to enteral feeding and to prevent complications such as aspiration. Normal gastric residual volumes are generally considered to be less than 250 mL.

Choice E reason: Using a plunger to administer medications through a gastrostomy tube is not always recommended. Medications should be administered slowly to prevent discomfort or harm, and the use of a plunger is not a standard practice across all healthcare settings.