The client is in the cardiac intensive care unit on dopamine, and BP increases to 210/130. Which action should the nurse take first?

Assess the client's neurological status.

Discontinue the client's dopamine.

Administer hydralazine intravenously.

Notify the client's healthcare provider.

Answer and Explanation

The Correct Answer is B

Dopamine is a potent catecholamine that exerts dose-dependent effects on the cardiovascular system by stimulating alpha and beta receptors. High-dose administration leads to profound vasoconstriction and increased systemic vascular resistance, which can precipitate a hypertensive crisis. Critical nursing management requires the immediate cessation of the causative inotropic agent to prevent end-organ damage such as intracranial hemorrhage or myocardial infarction.

Rationale:

A. Assessing the patient's level of consciousness is a necessary component of monitoring for encephalopathy during a hypertensive emergency. However, the nurse must first address the etiology of the soaring blood pressure to stop further physiological deterioration. Assessment is secondary to the immediate stabilization of hemodynamics through the removal of the offending drug.

B. The nurse’s primary action is to stop the dopamine infusion to halt the exogenous stimulation of alpha-1 adrenergic receptors. Because dopamine has a very short half-life, discontinuing the drip is the fastest way to begin lowering the blood pressure. This direct intervention addresses the safety risk before any other secondary or collaborative actions.

C. While IV antihypertensives like hydralazine are used to treat severe hypertension, administering a new medication while a vasopressor is still infusing is counterproductive. The nurse must first eliminate the source of the vasoconstriction before introducing pharmacological antagonists. Discontinuing the dopamine is the most efficient and prioritized nursing intervention in this clinical scenario.

D. The healthcare provider must be informed of the change in status, but this action is collaborative rather than an immediate life-saving measure. The nurse must exercise independent clinical judgment by stopping the infusion that is actively causing the 210/130 reading. Notification should occur only after the patient has been protected from the immediate pharmacological threat.

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Correct Answer is ["A","B","D","F","G"]

Explanation

Fall prevention in clinical settings requires a multifaceted strategy focused on identifying and mitigating environmental and physiological hazards. High-risk populations often exhibit sensory impairment or gait instability, necessitating proactive surveillance to maintain a safe therapeutic environment. Successful mitigation relies on a collaborative partnership between the interdisciplinary team, the client, and their support system to ensure consistent adherence to safety protocols.

Rationale:

A. Liquid on floor surfaces significantly reduces the coefficient of friction, creating an immediate slip hazard for ambulatory clients. Rapid removal of moisture is a fundamental environmental control measure to prevent orthopedic injuries or head trauma. This action must be performed immediately to maintain spatial safety in high-traffic patient care areas.

B. Encouraging clients to utilize the call system ensures that supervised mobility is maintained for those with impaired balance or strength. This practice prevents unassisted transfers that frequently lead to mechanical falls when the client overestimates their physical capacity. Consistent reinforcement of this habit is a key preventative intervention for inpatient safety.

C. Hallway grab bars are designed as static supports for stability while standing or in the bathroom, not as mobility aids for ambulation. Clients should be taught to use dynamic equipment like walkers or canes if they require support while walking long distances. Relying on wall-mounted bars for walking can lead to postural instability and falls.

D. Frequent observation allows the nurse to identify early indicators of restlessness, confusion, or unsafe behaviors that precede fall events. Close monitoring facilitates timely intervention when a client attempts to exit the bed without the necessary assistance. Vigilance is particularly crucial for clients with cognitive deficits or pharmacological-induced sedation.

E. Incontinent clients are at high risk for falls due to urinary urgency and the frequent need to ambulate to the bathroom. Assisting a client only once per shift is clinically inadequate to prevent toileting-related accidents and subsequent falls on wet surfaces. Frequent, scheduled toileting rounds are required to meet the client's elimination needs safely.

F. Educating the client and their family fosters a culture of safety awareness and empowers them to identify potential risks. When families understand the rationale behind fall precautions, they are more likely to comply with safety restrictions and alert staff to hazards. This engagement transforms the family into an active safety advocate.

G. Proper use of corrective lenses and hearing amplification is essential for maintaining environmental orientation and depth perception. Sensory deprivation increases the risk of tripping over obstacles or failing to hear auditory warnings from staff or equipment. Ensuring these devices are functional and in use optimizes the client's neurological processing of surroundings.

A. Secure the restraint to the bed frame using a slipknot. B. Ensure that the back of the vest is positioned on the client's back. C. Inspect the client's skin where the restraint is to be placed. D. Permit four fingers to slide between the client and the restraint.

Correct Answer is C

Explanation

Dementia-related agitation often stems from unmet needs or environmental overstimulation, necessitating a focus on safety and physical integrity. Before implementing mechanical immobilization, a thorough physical assessment is mandatory to establish a baseline and prevent iatrogenic injury. The nurse must prioritize the protection of cutaneous tissues, as frail elderly patients are highly susceptible to pressure-related trauma and localized ischemia during restrictive interventions.

Rationale:

A. Securing the device to the bed frame with a quick-release knot is a vital safety step during the actual application process. However, the nurse must complete a thorough pre-application assessment of the patient's physical status before initiating the tethering process. Ensuring the knot is accessible allows for rapid removal during a clinical emergency or fire.

B. Verifying that the vest is oriented correctly with the opening at the posterior prevents the risk of accidental strangulation or restricted thoracic expansion. While correct orientation is essential for device efficacy, it follows the initial assessment of the patient's skin and underlying physical condition. Proper fit ensures the device functions as intended without causing secondary physical harm.

C. Inspecting the skin is the highest priority to ensure there are no existing lesions or areas of compromised circulation before restraint. Applying a vest over damaged tissue can lead to rapid necrosis or exacerbate underlying skin breakdown due to friction and pressure. Documentation of the skin’s integrity provides a critical baseline for ongoing monitoring and legal compliance.

D. Maintaining adequate space between the patient and the material ensures that respiratory excursion and peripheral circulation are not impeded. While the "two-finger" or "four-finger" rule is a standard evaluative measure after the vest is on, it is a component of fitting rather than the initial assessment. The nurse must first ensure the site is healthy enough to tolerate the device.

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The client is in the cardiac intensive care unit on dopamine, and BP increases to 210/130. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The registered nurse preceptor plans to teach a new graduate registered nurse about nursing actions to prevent falls. Which actions should the preceptor include? Select All That Apply.

Correct Answer is ["A","B","D","F","G"]

Explanation

A nurse is caring for an agitated client with dementia who has a new order for a vest restraint. Which action should the nurse prioritize before applying the restraint?

Correct Answer is C

Explanation

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