The physician has ordered Dopamine for a patient in the ICU who has suffered a spinal cord injury. The nurse determines that the drug is having the desired effect when the assessment findings are:

Temperature of 96.8°F

Blood pressure 110/68

Respiratory rate of 20 breaths/min

Heart rate of 70 beats/min

Answer and Explanation

The Correct Answer is B

Choice A reason:

A temperature of 96.8°F is within the normal range for a human body (97.8°F to 99.1°F). However, it does not necessarily indicate the desired effect of Dopamine. Dopamine is primarily used to improve blood flow and cardiac output, particularly in critically ill patients. Therefore, temperature alone is not a reliable indicator of its effectiveness.

Choice B reason:

Blood pressure of 110/68 mmHg suggests that the Dopamine is effectively maintaining the patient's hemodynamic stability. Dopamine is often used to support blood pressure in patients with hypotension, particularly after spinal cord injuries. Maintaining an adequate blood pressure ensures that vital organs receive sufficient blood flow, which is a key therapeutic goal of Dopamine administration.

Choice C reason:

A respiratory rate of 20 breaths/min is considered normal for an adult (12-20 breaths/min). While normal respiratory rate is a positive sign, it is not a direct measure of Dopamine's effectiveness. Dopamine's primary action is on the cardiovascular system, so a normal respiratory rate alone does not necessarily indicate that the drug is having the desired effect.

Choice D reason:

A heart rate of 70 beats/min is within the normal range for adults (60-100 beats/min). Similar to the respiratory rate, while a normal heart rate is beneficial, it is not a direct indicator of Dopamine's effectiveness. Dopamine's role in improving cardiac output and blood pressure is more critical in assessing its desired effects.

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Correct Answer is A

Explanation

Choice A reason:

Arterial Blood Gas (ABG) analysis is the best method to determine the effectiveness of treatments in a client receiving mechanical ventilation. ABGs provide direct information about the patient's oxygenation, ventilation, and acid-base status, which are critical in managing acute respiratory failure.

Choice B reason:

While blood pressure is important for overall patient monitoring, it does not provide specific information about the effectiveness of ventilation and respiratory status. It is more related to hemodynamic stability.

Choice C reason:

Capillary refill can provide some information about peripheral perfusion but is not specific enough to assess the effectiveness of mechanical ventilation or respiratory treatments.

Choice D reason:

Heart rate is a vital sign that can indicate the patient's overall condition but does not specifically assess the effectiveness of ventilation or respiratory treatments. It should be considered along with other more specific respiratory assessments.

A. Obtain an order for a chest x-ray. B. Increase the PEEP. C. Perform endotracheal suctioning. D. Reposition the patient.

Correct Answer is C

Explanation

Choice A reason:

While obtaining a chest x-ray can help assess the patient's condition, it is not the immediate action needed in this situation. The patient's drop in SaO2 and agitation indicate an acute issue that needs to be addressed promptly.

Choice B reason:

Increasing the PEEP might help improve oxygenation, but it is not the first action to take. The presence of coarse crackles suggests the need to clear secretions first before adjusting ventilator settings.

Choice C reason:

Performing endotracheal suctioning is the appropriate immediate action. Coarse crackles indicate the presence of secretions in the airway, which can impair ventilation and oxygenation. Suctioning helps clear the airway and improve the patient's SaO2 levels.

Choice D reason:

Repositioning the patient can help with ventilation and comfort but is not the priority action when there are indications of airway obstruction. Clearing the airway through suctioning takes precedence in this scenario.

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The physician has ordered Dopamine for a patient in the ICU who has suffered a spinal cord injury. The nurse determines that the drug is having the desired effect when the assessment findings are:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the best method to determine the effectiveness of the current treatments?

Correct Answer is A

Explanation

A patient with Acute Respiratory Distress Syndrome is mechanically ventilated. Coarse crackles are heard over upper airways, the SaO2 has dropped to 85%, and the patient is agitated. Which action should the nurse take?

Correct Answer is C

Explanation

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