Norepinephrine 5 mcg/minute titrated by blood pressure per protocol has been prescribed for a patient in refractory shock. Before administering the drug, the nurse ensures which action?
Urine output is at least 30 mL/hour for 24 hours
Not receiving additional sympathomimetic medication
Has received adequate fluid replacement
Heart rate is less than 100
The Correct Answer is C
A. Urine output is at least 30 mL/hour for 24 hours: Monitoring urine output is important for assessing renal perfusion and overall response to therapy, but it is not a prerequisite for initiating norepinephrine. Vasopressor therapy can be required even if urine output is low, especially in refractory shock.
B. Not receiving additional sympathomimetic medication: While avoiding additive sympathomimetics reduces the risk of excessive vasoconstriction or arrhythmias, it is not the primary safety check before starting norepinephrine. Concurrent medications can be managed during titration under close monitoring.
C. Has received adequate fluid replacement: Norepinephrine is a potent vasoconstrictor, and its effectiveness depends on sufficient circulating volume. Administering it before adequate fluid resuscitation can worsen tissue perfusion, increase risk of ischemia, and potentially cause cardiovascular collapse. Ensuring fluid replacement is a critical step in managing refractory shock.
D. Heart rate is less than 100: Heart rate is monitored during norepinephrine infusion, as the drug can cause reflex bradycardia or tachyarrhythmias. However, an elevated heart rate is not an absolute contraindication; the priority is confirming adequate intravascular volume before initiating vasopressor therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Remove the bite block and perform oral hygiene every 2 hours: While oral hygiene is important to reduce bacterial colonization and prevent ventilator-associated pneumonia, removing the bite block does not directly prevent aspiration and may risk ET tube displacement. Oral care alone is insufficient to address aspiration risk during tube feeding.
B. Use chest physiotherapy to allow secretions to be suctioned: Chest physiotherapy helps mobilize pulmonary secretions but does not prevent aspiration of gastric contents from the oropharynx or stomach. Suctioning may be necessary if secretions accumulate, but it is not a primary preventative measure for aspiration during feeding.
C. Maintain cuff pressure to prevent gastric secretions from entering trachea: Proper ET tube cuff inflation helps reduce microaspiration of oropharyngeal secretions but does not completely prevent reflux of gastric contents. Cuff pressure maintenance is important, yet positioning remains a more effective intervention to minimize aspiration risk during enteral feeding.
D. Keep head of bed elevated at least 30-45 degrees: Elevating the head of the bed reduces the risk of aspiration by using gravity to minimize reflux of gastric contents into the oropharynx and trachea. This intervention is evidence-based, simple, and highly effective in patients with enteral feedings and an ET tube.
Correct Answer is D
Explanation
A. Position flat in bed with sandbags at head: After a transsphenoidal hypophysectomy, the patient’s head is typically elevated to reduce intracranial pressure and minimize the risk of cerebrospinal fluid (CSF) leakage. Lying flat with sandbags would increase ICP and is contraindicated.
B. Cough vigorously and deep breathe every 2 hours: Forceful coughing and straining increase intracranial pressure and can disrupt the surgical site, leading to CSF leakage or bleeding. Patients are usually instructed to avoid coughing, sneezing, or straining postoperatively.
C. Take replacement growth hormone for a few months: Hormone replacement depends on which pituitary hormones are affected and is individualized. Some patients may require lifelong hormone therapy, not just a few months, and preoperative teaching focuses on surgical precautions rather than post-op medication timing.
D. Report clear drainage from nose: Clear, watery nasal drainage may indicate CSF leak, a serious postoperative complication that increases the risk of meningitis. Prompt reporting allows early assessment and intervention, making this a critical teaching point for patient safety.
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