Nokea
A nurse is preparing to administer a prescribed adrenergic agent to a client who is in shock. Before administering the drug, the nurse would assess for and document which of the following as a sign of shock?
- A. Increased temperature
- B. Reddish/pinkish skin
- C. Dry, dehydrated skin
- D. Changes in consciousness
Correct Answer: D
Rationale: Changes in consciousness are a key sign of shock, indicating inadequate cerebral perfusion, and should be documented before administering adrenergic drugs.
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The nurse administers isoproterenol (Isuprel) to a client. Which of the following would most likely occur?
- A. Decreased heart rate
- B. Increased use of glucose
- C. Decreased gastric motility
- D. Constriction of coronary blood vessels
- E. Wakefulness
Correct Answer: B,C,E
Rationale: Isoproterenol stimulates beta receptors, leading to increased heart rate, increased glucose metabolism, decreased gastric motility, dilation of coronary blood vessels, and wakefulness.
While assessing a client, the nurse observes hives and flushing. The client reports itching and a tightness in the throat. The nurse would identify which of the following nursing diagnoses?
- A. Risk for Allergy Response
- B. Ineffective Tissue Perfusion
- C. Decreased Cardiac Output
- D. Risk for Injury
Correct Answer: A
Rationale: Hives, flushing, itching, and throat tightness indicate an allergic reaction, making Risk for Allergy Response the appropriate nursing diagnosis.
After administering dobutamine to a client, the nurse would assess the client closely for which adverse reaction?
- A. Cardiac arrhythmias
- B. Urinary retention
- C. Elevated temperature
- D. Sleeplessness
Correct Answer: A
Rationale: Dobutamine commonly causes cardiac arrhythmias, such as bradycardia or tachycardia, due to its beta-adrenergic stimulation.
A nurse is teaching a client how to use an auto-injector as treatment for an allergic reaction. Which statement by the client indicates the need for additional teaching?
- A. I should not touch the orange or black tip on the small end.
- B. I should administer the dose and then call 9-1-1 if I'm alone.
- C. I should inject the black tip into my outer thigh.
- D. I need to massage the site after removing the device.
Correct Answer: B
Rationale: In an emergency, the client should call 9-1-1 before administering the auto-injector to ensure prompt medical assistance.
A client is prescribed dopamine. Which of the following would the nurse include in the client's plan of care?
- A. Administering dopamine only via IV route
- B. Maintaining a fixed rate of administration
- C. Monitoring blood pressure every half hour
- D. Diluting dopamine with sodium bicarbonate
Correct Answer: A
Rationale: Dopamine must be administered intravenously to ensure rapid and controlled delivery, with blood pressure monitored frequently to titrate the dose.