The nurse is caring for a client with shock of unknown etiology whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure. Which of the following prescribed interventions should the nurse question? A)Infuse normal saline at 250 mL/hour. B)Keep head of bed elevated to 30 degrees. C)Give nitroprusside unless systolic BP 90 mm Hg.

Question

The nurse is caring for a client with shock of unknown etiology whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure. Which of the following prescribed interventions should the nurse question?
A)Infuse normal saline at 250 mL/hour.
B)Keep head of bed elevated to 30 degrees.
C)Give nitroprusside unless systolic BP <90 mm Hg.
D)Administer dobutamine to keep systolic BP >90 mm Hg.

Quizplus · Accepted Answer

The client's elevated pulmonary artery wedge pressure indicates volume excess. A normal saline infusion at 250 mL/hour will exacerbate this. The other actions are appropriate for the client.

The Nurse Is Caring for a Client with Shock of Unknown