The intensive care nurse (ICU) cares for a group of assigned clients.
The nurse should initially follow-up with the client who is
The intensive care nurse (ICU) cares for a group of assigned clients.
The nurse should initially follow-up with the client who is
A. mechanically ventilated and not taking spontaneous breaths while in the assist-control (AC) mode.
[26%]
B. being treated for a flail chest, reporting chest pain with inhalation.
[17%]
C. noted to have gentle bubbling in the water seal chamber of their chest tube when coughing.
[5%]
D. receiving intravenous (IV) dopamine via a peripheral vascular access device and reports pain at the IV site.
[51%]
Statistics
Subject/Lesson
Subject
Critical Care
Lesson
Critical Care Concepts
Client Need
Test Plan
Management of Care
Related Topic
Establishing Priorities
Item Type
Item Type
Analysis
Explanation
Choice D is correct. Dopamine is a vasopressor and is indicated in the treatment of shock. Dopamine is a vesicant, and a significant adverse effect of dopamine is that it can extravasate and cause severe tissue damage. This emphasizes why this medication should be infused through a central line to prevent this adverse complication. The nurse should immediately attend to this client and stop the infusion. If extravasation is suspected, the nurse should stop the infusion and aspirate any remaining IV fluid from the catheter.
Choice A is incorrect. The mechanically ventilated client has a protected airway, and the lack of spontaneous respirations explains why the client is receiving ventilation via assist control. Assist control provides full airway protection and delivers a preset number of breaths at a preset amount of tidal volume. The nurse does not need to follow up with the client as the ventilator provides appropriate treatment.
Choice B is incorrect. A flail chest occurs from blunt force trauma and causes the client to have pain with inspiration. Another classic manifestation of a flail chest is paradoxical chest wall movement (inward thorax movement during inspiration, with outward movement during expiration). This is an expected finding.
Choice C is incorrect. Gentle bubbling in the water seal chamber of their chest tube when coughing is normal and does not require follow-up. Continuous bubbling in the water seal chamber would require follow-up that suggests an air leak.
Related Videos
2 Key Topics
Spectrum of Stability
15.5 Prioritization Part 1
Additional Info
✓ Dopamine is a vasopressor that, at certain doses, may stimulate the alpha- and beta-receptors to increase mean arterial perfusion (MAP)
✓ The medication is titrated based on the client's MAP
✓ When caring for a client receiving dopamine, the nurse should continuously assess the client's heart rate and rhythm, as certain doses of this medication may cause tachydysrhythmias
✓ The client should have their peripheral vascular access device monitored closely as this medication is a vesicant
✓ It is highly preferred for this medication to be infused through a central line
✓ Chest pain, decreased urinary output, and dysrhythmias should be reported immediately to the physician
