A patient who is hypotensive is receiving dopamine, an adrenergic agonist IV at the rate of 6 mcg/kg/min. Which intervention should the nurse implement when administering this medication?
Implement seizure precautions.
Monitor serum potassium frequently.
Ensure pump accuracy to prevent toxicity.
Encourage the patient to ambulate every hour.
The Correct Answer is C
Choice A reason: This is incorrect because seizure precautions are not indicated for dopamine administration. Dopamine does not lower the seizure threshold or cause convulsions.
Choice B reason: This is incorrect because monitoring serum potassium frequently is not necessary for dopamine administration. Dopamine does not affect potassium levels or cause hyperkalemia or hypokalemia.
Choice C reason: This is correct because ensuring pump accuracy to prevent toxicity is essential for dopamine administration. Dopamine is a potent vasoconstrictor that can cause tissue necrosis, gangrene, and hypertension if overdosed.
Choice D reason: Dopamine is given to hypotensive patients, meaning they may be weak, dizzy, or at risk of falls. Ambulating frequently could worsen hypotension and increase fall risk rather than help the patient. Instead, the nurse should monitor the patient’s hemodynamic status and ensure bed rest as needed until blood pressure stabilizes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A is correct because a distended bladder can displace the uterus and prevent it from contracting properly, leading to increased bleeding and risk of infection. The nurse should check for a distended bladder and assist the client to empty it if needed.
Choice B is incorrect because reviewing the hemoglobin is not a priority action. The hemoglobin may not reflect the current blood loss and may be done later.
Choice C is incorrect because massaging the uterus is not necessary if it is firm. Massaging a firm uterus can cause overstimulation and pain.
Choice D is incorrect because increasing intravenous infusion is not a priority action. The client may not need additional fluids if the bleeding is moderate and the vital signs are stable.
Correct Answer is C
Explanation
Choice A reason: Scheduling the child for a STAT magnetic resonance imaging (MRI) of the neck is not a priority action for the nurse. MRI is a diagnostic test that uses magnetic fields and radio waves to produce images of the internal structures of the body. MRI of the neck may be useful to rule out other causes of respiratory distress, such as tumors, abscesses, or foreign bodies, but it is not an urgent procedure. Moreover, MRI requires the child to lie still for a long time, which may be difficult or impossible for a child who is anxious and in respiratory distress.
Choice B reason: Providing a nebulizer treatment with bronchodilators is not a suitable action for the nurse. Nebulizer is a device that delivers medication in the form of a mist that can be inhaled into the lungs. Bronchodilators are medications that relax the smooth muscles of the airways and improve airflow. Nebulizer treatment with bronchodilators may be helpful for children with respiratory distress caused by asthma, bronchiolitis, or chronic obstructive pulmonary disease, but not for children with respiratory distress caused by upper airway obstruction, which is the most likely scenario for this child.
Choice C reason: Obtaining bedside trays for intubation or tracheotomy by the healthcare provider is the most appropriate action for the nurse. Intubation is a procedure that involves inserting a tube through the mouth or nose into the trachea to secure the airway and provide ventilation. Tracheotomy is a surgical procedure that involves creating an opening in the neck and inserting a tube into the trachea to bypass the upper airway obstruction. Both procedures are life-saving interventions for children with respiratory distress caused by upper airway obstruction, which is the most likely scenario for this child. The nurse should prepare the necessary equipment and assist the healthcare provider in performing these procedures.
Choice D reason: Beginning prescribed intravenous antibiotic administration is not a relevant action for the nurse. Antibiotics are medications that kill or inhibit the growth of bacteria that cause infections. Antibiotics may be indicated for children with respiratory distress caused by bacterial infections, such as pneumonia, tonsillitis, or epiglottitis, but not for children with respiratory distress caused by non-infectious causes, such as foreign bodies, anaphylaxis, or congenital anomalies. Moreover, antibiotics are not an immediate intervention for respiratory distress, as they take time to exert their effects.
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