The nurse is caring for a client with vasodilatory shock who is receiving a vasopressin infusion. Which nursing intervention is most important for this client?
The nurse is caring for a client with vasodilatory shock who is receiving a vasopressin infusion. Which nursing intervention is most important for this client?
A. Encouraging fluid intake of at least 2 liters per day
[4%]
B. Checking blood pressure every 15 minutes
[79%]
C. Monitoring urine output every 2 hours
[11%]
D. Assessing for signs of myocardial ischemia every 4 hours
[6%]
Statistics
Subject/Lesson
Subject
Critical Care
Lesson
Critical Care Concepts
Client Need
Test Plan
Pharmacological and Parenteral Therapies
Related Topic
Expected Actions/Outcomes
Item Type
Item Type
Analysis
Explanation
Choice B is correct. This option is the most important because vasopressin infusion aims to increase blood pressure in vasodilatory shock by inducing vasoconstriction. Frequent monitoring of blood pressure a minimum of every 15 minutes allows for real-time assessment of the client's response to vasopressin therapy and ensures that blood pressure is maintained within the target range to support adequate tissue perfusion.
Choice A is incorrect. Fluid intake is important for clients with shock to maintain intravascular volume, encouraging a specific fluid intake of 2 liters per day may not be appropriate without considering the client's individual fluid status and underlying condition.
Choice C is incorrect. Urine output can be affected by various factors, including fluid status, renal function, and medication effects, but changes in urine output may not always directly correlate with the client's hemodynamic status or response to vasopressin therapy.
Choice D is incorrect. Assessing for signs of myocardial ischemia is crucial in clients with shock, as inadequate tissue perfusion can lead to cardiac compromise. However, in the context of a client receiving vasopressin infusion for vasodilatory shock, assessing for myocardial ischemia every 4 hours is not as immediate a concern as monitoring blood pressure every 15 minutes.
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Additional Info
✓ Vasopressin, also known as antidiuretic hormone (ADH), is a hormone produced by the hypothalamus and released by the posterior pituitary gland. It plays a crucial role in regulating water balance and blood pressure in the body.
✓ Vasopressin is typically administered via intravenous infusion as a continuous infusion. The nurse follows established protocols and guidelines for IV medication administration, including the use of infusion pumps for accurate delivery and monitoring.
✓ During vasopressin infusion, the nurse closely monitors the client's response to therapy, including hemodynamic parameters such as blood pressure, heart rate, and urine output. Frequent assessment is essential for detecting signs of inadequate perfusion or adverse effects, allowing for timely adjustments in vasopressin dosage or infusion rate.
