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 B
Explanation
A. Mini mental status exam at admission and discharge
Useful for cognitive function but not for acute changes.
B. Performing serial Glasgow Coma Scale exams
The GCS is the best tool for tracking changes in neurologic status over time.
C. Assessing pupils for reactivity, equality, symmetry, and accommodation
Important but not comprehensive.
D. Obtaining vital signs every four hours
Useful but does not specifically assess neurologic function.
Correct Answer is C
Explanation
A. Sudden onset of chest pain and copious sputum
These are more consistent with pulmonary edema or a respiratory infection, not DIC.
B. Foul-smelling concentrated urine
This is suggestive of a urinary tract infection (UTI) or dehydration but is not a hallmark sign of DIC.
C. Oozing blood from IV sites & previous venipuncture sites
DIC is a disorder of excessive clotting and subsequent bleeding. Uncontrolled bleeding from IV sites, surgical wounds, or mucous membranes is a classic sign.
D. Reddened, inflamed central line catheter site
While redness around a catheter site may indicate infection, it is not a defining feature of DIC.
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