A patient who has neurogenic shock is receiving a phenylephrine infusion through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action?

Question

Quizplus · Accepted Answer

The coldness and pallor at the infusion site suggest extravasation of the phenylephrine. The nurse should discontinue the IV and,if possible,infuse the drug into a central line. An apical pulse of 58 beats/min is typical for neurogenic shock but does not indicate an immediate need for nursing intervention. A 28-mL urinary output over 1 hour would require the nurse to monitor the output over the next hour,but an immediate change in therapy is not indicated. Warm,dry skin is consistent with early neurogenic shock,but it does not indicate a need for a change in therapy or immediate action.

A Patient Who Has Neurogenic Shock Is Receiving a Phenylephrine