A client who is in shock is receiving a continuous IV infusion of a sympathomimetic dopamine. Which intervention should the nurse include in this client's plan of care?

Obtain a blood pressure every 15 minutes.

Monitor the client's complete blood count (CBC) daily.

Review creatinine and blood urea nitrogen results.

Measure the client's urinary output daily.

Answer and Explanation

The Correct Answer is A

A. Dopamine, a sympathomimetic agent, can cause significant changes in blood pressure. Monitoring blood pressure every 15 minutes is crucial to assess the client's response to the medication and to detect any adverse effects, such as hypertension or hypotension, promptly.
B. Monitoring CBC is important but not as immediately critical in this situation as monitoring blood pressure.
C. While reviewing creatinine and BUN results is important for overall kidney function, it is not the most immediate priority when administering dopamine for shock.
D. Measuring urinary output is important for assessing renal perfusion but should be done more frequently than daily in a client receiving dopamine for shock.

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Correct Answer is A

Explanation

A. Spasms of the neck and back can be symptoms of acute dystonia, a side effect of antipsychotic medications like chlorpromazine. Anticholinergic drugs such as benztropine mesylate can help manage these symptoms.
B. Spasms are not an expected side effect of chlorpromazine and require intervention rather than acceptance.
C. Refusing to administer chlorpromazine without consulting the healthcare provider may be premature; the priority is to address the symptoms.
D. Decreasing the dose and notifying the healthcare provider may be necessary, but first, it’s essential to determine if anticholinergic medication is required to address the acute symptoms.

A. Turn the overhead lights on while giving instructions. B. Stand behind the client to avoid intimidation. C. Provide handouts written at a 12th grade reading level. D. Use background music to promote relaxation.

Correct Answer is A

Explanation

A. Turning on overhead lights ensures that the client can see the instructions clearly, which is particularly important for older adults who may have visual impairments. Adequate lighting helps improve comprehension and reduces the risk of misunderstandings.
B. Standing behind the client may cause confusion or discomfort. It is better to face the client while communicating.
C. Handouts should be written at a lower reading level, typically around the 5th to 6th grade, to ensure that most clients can understand them, especially older adults.
D. Background music may be distracting rather than helpful during the provision of important instructions.

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A client who is in shock is receiving a continuous IV infusion of a sympathomimetic dopamine. Which intervention should the nurse include in this client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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