A client who is in shock is receiving norepinephrine in addition to IV fluids. What principle should influence the nurse's care planning during the administration of a vasoactive drug?
The drug should be discontinued immediately after blood pressure increases.
The drug dose should be tapered down once vital signs improve.
The client should have arterial blood gases drawn every 10 minutes during treatment.
The infusion rate should be titrated according to client's subjective sensation of adequate perfusion.
The Correct Answer is B
A. The drug should be discontinued immediately after blood pressure increases: Stopping norepinephrine abruptly can cause a sudden drop in blood pressure. Vasoactive drugs must be adjusted gradually to maintain stable perfusion as the client responds. Sudden withdrawal places the client at risk for rapid hemodynamic deterioration.
B. The drug dose should be tapered down once vital signs improve: Vasoactive drugs like norepinephrine require gradual titration based on the client’s hemodynamic response to avoid abrupt shifts in perfusion. As blood pressure and cardiac stability improve, doses are slowly reduced while monitoring for recurrent hypotension.
C. The client should have arterial blood gases drawn every 10 minutes during treatment: Frequent ABGs are unnecessary and impractical unless the client is experiencing severe respiratory instability. Hemodynamic monitoring, vital signs, and urine output provide more precise ongoing indicators of perfusion during vasoactive therapy.
D. The infusion rate should be titrated according to client's subjective sensation of adequate perfusion: Clients in shock cannot reliably assess their own perfusion status due to impaired cognition, altered mental status, or stress. Vasoactive medications must be titrated based on objective data such as MAP, blood pressure, and urine output.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. right-sided tension pneumothorax: Tracheal deviation away from the affected side, hypotension, tachycardia, and tachypnea are classic signs of tension pneumothorax. Since the trachea deviates to the left, the problem is on the right side. This is a life-threatening emergency requiring immediate decompression.
B. fall chest with sternal involvement: Flail chest from sternal or rib fractures causes paradoxical chest movement and respiratory distress, but tracheal deviation is not a typical finding. Hypotension may occur with associated injuries, but it does not explain the observed tracheal shift.
C. left-sided tension pneumothorax: A left-sided tension pneumothorax would push the trachea to the right, not to the left. The direction of tracheal deviation helps localize the affected side. This does not match the client’s presentation.
D. fractured ribs with splinting of the chest wall: Rib fractures can cause pain and shallow breathing, but they rarely cause tracheal deviation or severe hypotension. Splinting alone does not account for the hemodynamic instability or mediastinal shift seen in tension pneumothorax.
Correct Answer is D
Explanation
A. bone marrow transplant: Bone marrow transplant does not reverse hyperacute rejection. This type of rejection occurs because of pre-existing antibodies, and once the process begins, the damage progresses too rapidly for immune-modulating procedures like marrow transplant to be effective.
B. immediate dialysis to prevent damage to the new kidney: Dialysis may be needed after the kidney is removed, but it does not stop the rejection process. Hyperacute rejection results in irreversible vascular injury to the graft, so dialysis cannot salvage the transplanted organ.
C. high-dose intravenous cyclosporin therapy: Cyclosporin is useful for preventing or managing acute rejection, not hyperacute rejection. In hyperacute rejection, the tissue damage occurs within minutes to hours, and immunosuppressive therapy cannot reverse the destruction once it has begun.
D. removal of the transplanted kidney: Hyperacute rejection is caused by preformed antibodies that immediately attack the graft, leading to rapid thrombosis and necrosis. The transplanted organ is nonviable, so prompt removal is necessary to prevent systemic complications such as sepsis or disseminated clotting.
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