Questions 64

NCLEX-RN

NCLEX-RN Test Bank

Cardiovascular Pharmacology NCLEX RN Questions

Extract:

The following scenario applies to the next 1 items
The nurse in the emergency department (ED) is caring for a client with septic shock
Item 1 of 1
Nurses' Notes
1400: Follow-up assessment after the infusion of 30 mL/kg of 0.9% saline bolus (1850 mL total) was infused. Vital signs: T 103.4° F (39.7° C), P 104, RR 22, BP 90/61, pulse oximetry reading 95% on room air.
1410: The physician was notified of the vital signs, and a verbal order for a dopamine drip was received for 5 mcg/kg/minute to titrate to a MAP of 65 mm Hg. The order was read back and verified.
1415: Dopamine infusion started in the client's right antecubital peripheral vascular access device.
1445: The client reports 'stinging' pain at the vascular access site. The site had erythema, swelling, and tenderness when touched. The infusion was stopped.


Question 1 of 5

The nurse reviewed all nursing note entries and notified the physician of the vascular access device assessment findings. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress

Action to Take

Obtain a prescription for phentolamine
Flush the vascular access device
Aspirate any residual medication
Restart the infusion at a lower rate.

Potential Condition

Extravasation
Hematoma
Infiltration
Phlebitis.

Parameter to Monitor

Urinary output
Neurovascular status of affected extremity
Drainage at vascular access site
Pain level.

Correct Answer: B, A, C

Rationale: The client is experiencing extravasation (
B) due to dopamine causing stinging, erythema, and swelling. Actions include obtaining phentolamine (A, an antidote for vasopressor extravasation) and aspirating residual medication (
A). Monitor neurovascular status (
C) and pain level (
C) to assess progress.

Extract:


Question 2 of 5

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Question 3 of 5

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Question 4 of 5

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Question 5 of 5

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