The client who is experiencing septic shock is started on norepinephrine by intravenous drip via pump. Which frequent assessments should the nurse prioritize while administering this medication? (Select All that Apply)
Color of conjunctiva
Deep tendon reflexes
IV Insertion site
Blood pressure and heart rate
Hourly urine output
Correct Answer : C,D,E
A. Color of conjunctiva
While assessing for signs of perfusion is important, conjunctival color is not a primary assessment for norepinephrine administration. Perfusion is better assessed through blood pressure, heart rate, capillary refill, and urine output.
B. Deep tendon reflexes
Norepinephrine primarily affects vascular tone and cardiac output. Deep tendon reflexes are not a priority assessment for this medication.
C. IV Insertion site
Norepinephrine is a vasopressor, and extravasation can cause severe tissue necrosis. Frequent monitoring of the IV site is necessary to prevent complications.
D. Blood pressure and heart rate
Norepinephrine increases blood pressure and heart rate through vasoconstriction. Continuous monitoring is required to assess for excessive hypertension, tachycardia, or inadequate response to therapy.
E. Hourly urine output
Urine output is an essential indicator of organ perfusion. Since norepinephrine is used to maintain adequate blood pressure and perfusion in septic shock, monitoring urine output helps assess the effectiveness of treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Atropine 1 mg IV push
A C3 spinal cord injury disrupts sympathetic control, causing bradycardia. Atropine is the first-line treatment for symptomatic bradycardia.
B. Epinephrine 1 mg IV
Epinephrine is used for cardiac arrest, not initial management of bradycardia.
C. Adenosine 6 mg IV push
Adenosine is used for supraventricular tachycardia, not bradycardia.
D. Milrinone 50 mcg/kg IV push
Milrinone is an inotrope used in heart failure, not bradycardia.
Correct Answer is ["A","C","D"]
Explanation
A. Administer each unit of blood over 3–4 hours
Older clients with CHF cannot tolerate rapid fluid shifts. Blood should be administered slowly (over 3–4 hours per unit) to prevent fluid overload.
B. Anticipate an order for acetaminophen
Acetaminophen is not routinely given before blood transfusions unless the client has a history of febrile reactions.
C. Anticipate an order for furosemide administration
Loop diuretics like furosemide may be ordered between units to prevent fluid overload in CHF patients.
D. Assess for signs and symptoms of fluid overload
CHF patients are at high risk for fluid overload, leading to dyspnea, crackles, and increased BP.
E. Anticipate administration of fresh frozen plasma (FFP) for the next transfusion
FFP is given for coagulation disorders, not for treating anemia in a GI bleed.
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