The nurse is caring for a client who has been successfully resuscitated following a cardiac arrest and is now on an IV infusion of epinephrine. The cardiac monitor shows a heart rate of 120 beats/minute. What should be the nurse's best action?

Maintain the infusion because the client had a cardiac arrest.

Continue to monitor the client's rhythm closely.

Suggest that the client's medication be changed to norepinephrine.

Ask the physician if the dose can be decreased.

Answer and Explanation

The Correct Answer is D

A. Maintain the infusion because the client had a cardiac arrest: While epinephrine is essential during cardiac arrest, continuing a high-dose infusion post-resuscitation without reassessment may lead to complications like tachycardia, hypertension, and increased myocardial oxygen demand.

B. Continue to monitor the client's rhythm closely: Ongoing monitoring is important, but it is a passive intervention. The heart rate of 120 bpm may reflect excessive adrenergic stimulation from epinephrine, and further action is needed to prevent deterioration.

C. Suggest that the client's medication be changed to norepinephrine: Norepinephrine is another vasopressor that has less of a beta-1 adrenergic effect compared to epinephrine. It is primarily used for hypotension and septic shock, not as a direct substitute for epinephrine post-cardiac arrest. Changing to another vasopressor without indication is not the best initial step.

D. Ask the physician if the dose can be decreased: A heart rate of 120 bpm may indicate that the epinephrine dose is too high, causing sympathetic overstimulation. Prolonged or excessive tachycardia increases myocardial oxygen demand, which can be detrimental, especially in a post-arrest heart. Decreasing the dose can help prevent arrhythmias or myocardial ischemia, making this the most appropriate and proactive action.

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Correct Answer is ["200"]

Explanation

Volume ordered is 1 L.

Convert the total volume to milliliters (mL)

1 L = 1000 mL.

Total volume in mL = 1 L × 1000 mL/L = 1000 mL

Total infusion time = 5 hours

Calculate the infusion rate in milliliters per hour (mL/hr).

Infusion rate (mL/hr) = Total volume (mL) / Total infusion time (hours)

= 1000 mL / 5 hours

= 200

The appropriate setting is 200 mL/hr.

A. Review daily the necessity of the central venous catheter. B. Maintain a pressure of 300 mm Hg on the flush bag. C. Cleanse the insertion site daily with isopropyl alcohol. D. Change the pressurized tubing system and flush bag daily.

Correct Answer is A

Explanation

A. Review daily the necessity of the central venous catheter: One of the most effective strategies to reduce the risk of catheter-related bloodstream infections is to remove the central line as soon as it is no longer needed. Daily evaluation of necessity prevents prolonged catheter use, which significantly increases infection risk. Removing the source of potential infection is the ultimate preventative action.

B. Maintain a pressure of 300 mm Hg on the flush bag: While maintaining appropriate flush pressure is important for catheter patency and preventing blood clots, it does not play a direct role in preventing bloodstream infections. This action is more related to ensuring adequate line function rather than infection control.

C. Cleanse the insertion site daily with isopropyl alcohol: Current guidelines recommend using chlorhexidine-based solutions rather than isopropyl alcohol for skin antisepsis due to better antimicrobial efficacy. Daily site care is important, but the choice of antiseptic is critical in reducing infection risk.

D. Change the pressurized tubing system and flush bag daily: Tubing and flush systems should be changed typically every 72–96 hours unless contamination is suspected. Changing them daily is not recommended and does not provide added protection against infection it may even increase risk with unnecessary manipulation.

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The nurse is caring for a client who has been successfully resuscitated following a cardiac arrest and is now on an IV infusion of epinephrine. The cardiac monitor shows a heart rate of 120 beats/minute. What should be the nurse's best action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A post-op client is to receive the following: D5%W/0.45% NS 1 L to infuse over 5 hours. What is the appropriate setting on an infusion pump in milliliters per hour? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["200"]

Explanation

The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which action by the nurse best reduces the risk of catheter-related bloodstream infection (CRBSI)?

Correct Answer is A

Explanation

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