The patient is receiving norepinephrine (Levophed). When monitoring the patient's blood pressure, the nurse notes a pressure of 230/120 mmHg. What is the priority nursing action?
1. Assess the patient for signs/symptoms of a stroke.
2. Notify the physician.
3. Slow the rate of the infusion until the physician assesses the patient.
4. Stop the infusion.
Correct Answer: 4
Rationale: Discontinuing the infusion results in a reversal of adverse effects such as hypertension. The nurse would notify the physician, but this should occur after discontinuing the infusion. The infusion must be stopped, not slowed, before the patient experiences the adverse effects of extreme hypertension.
You might also like to view...
A roller sheet has been placed under an elderly client who is receiving treatment for failure to thrive. When using a roller sheet in a client's care, the nurse must
A) Keep the siderails raised to prevent the client from rolling off the side of the bed. B) Ensure that the roller sheet is kept dry and wrinkle-free. C) First ensure that the client is able to roll side-to-side independently. D) Insert an indwelling urinary catheter to protect the roller sheet from urine.
During the health history, the mother of a 4-month-old child tells the nurse she is concerned that her baby is not doing what he should be at this age. What is the nurse's best response?
A) "I'll be able to tell you more after I do his physical." B) "Fill out the questionnaire and then I can let you know." C) "Tell me what concerns you." D) "All mothers worry about their babies. I'm sure he's doing well."
You are asked to assist the patient into the dorsal lithotomy position. You know that the
A) patient's feet should be in stirrups. B) physician will be examining the patient's back. C) patient will be lying on the abdomen. D) patient must be in the side-lying position.
When the older adult confides to the home health nurse that he wants to build muscle mass so he can look good at the apartment pool, the nurse recommends:
a. aerobic exercise. b. stretching exercise. c. resistance exercise. d. tai chi exercise.