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A nurse is caring for a client in the ICU

Exhibits

For each potential nursing action, click to specify if the action is essential, nonessential, or contraindicated for the client.

A.

Administer furosemide

B.

Administer ordered Epinephrine drip

C.

Administer ordered low dose dopamine

D.

Insert an indwelling urinary catheter.

E.

Administer ordered nitroglycerin

F.

Administed 0.9% NS 500ML bolus

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

  • Administer furosemide: The patient has signs of pulmonary edema which needs to be managed.
  • Administer ordered Epinephrine drip: Epinephrine is crucial for managing hemodynamic instability.
  • Insert an indwelling urinary catheter: Monitoring urine output helps assess kidney function and fluid balance.
  • Administer ordered low dose dopamine: Useful for maintaining renal perfusion and blood pressure.
  • Administered 0.9% NS 500 mL bolus: Helps address hypotension and volume deficit.
  • Administer ordered nitroglycerin: Not needed in this acute post-arrest phase unless specifically indicated for managing ongoing angina or heart failure symptoms.


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Related Questions

Correct Answer is []

Explanation

1. Condition: Acute Compartment Syndrome

Justification: The presence of severe pain, swelling, numbness, and a weak radial pulse along with delayed capillary refill are classic signs of acute compartment syndrome. Immediate surgical intervention (fasciotomy) is necessary to relieve the pressure within the muscle compartments.

2. Actions to Take

Prepare for Fasciotomy:

Justification: This surgical procedure will relieve the internal pressure causing the symptoms.

Request Prescription for Pain Medication:

Justification: Adequate pain management is important for client comfort and can also indicate response to treatment.

3. Parameters to Monitor

Neurovascular Status:

Justification: Monitoring for further deterioration of symptoms such as worsening numbness or weak pulses is essential.

WBC Count:

Justification: Helps in the broader assessment of possible infection, though not directly related to acute compartment syndrome

Correct Answer is C

Explanation

A. Tachypnea is not a primary sign of increased intracranial pressure but might be seen in other conditions.

B. Bilateral weakness of extremities can indicate severe brain injury but is not the most specific sign of increased intracranial pressure.

C. Decreased level of consciousness is a direct sign of increased intracranial pressure affecting brain function.

D. Hypotension is not a typical manifestation of increased intracranial pressure; increased ICP more commonly leads to hypertension.

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