The nurse is caring for a client with neurogenic shock who is receiving a phenylephrine infusion through a left forearm IV. Which of the following assessment information obtained by the nurse indicates a need for immediate action?
A)The client's IV infusion site is cool and pale.
B)The client has warm, dry skin on the extremities.
C)The client has an apical pulse rate of 58 beats/minute.
D)The client's urine output has been 28 mL over the last hour.

Question

Quizplus · Accepted Answer

The coldness and pallor at the infusion site suggest extravasation of the phenylephrine which can lead to tissue sloughing. The nurse should discontinue the IV and, if possible, infuse the medication into a central line. An apical pulse of 58 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.

The Nurse Is Caring for a Client with Neurogenic Shock