The patient with neurogenic shock is receiving a phenylephrine ...

[erika]

The patient with neurogenic shock is receiving a phenylephrine (Neo-Synephrine) infusion through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action?
 
  a. The patient's heart rate is 58 beats/minute.
  b. The patient's extremities are warm and dry.
  c. The patient's IV infusion site is cool and pale.
  d. The patient's urine output is 28 mL over the last hour.

Question 2

The following interventions are ordered by the health care provider for a patient who has respiratory distress and syncope after eating strawberries. Which will the nurse complete first?
 
  a. Start a normal saline infusion.
  b. Give epinephrine (Adrenalin).
  c. Start continuous ECG monitoring.
  d. Give diphenhydramine (Benadryl).

[yeungji]

Answer to Question 1

ANS: C
The coldness and pallor at the infusion site suggest extravasation of the phenylephrine. 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.

Answer to Question 2

ANS: B
Epinephrine rapidly causes peripheral vasoconstriction, dilates the bronchi, and blocks the effects of histamine and reverses the vasodilation, bronchoconstriction, and histamine release that cause the symptoms of anaphylaxis. The other interventions are also appropriate but would not be the first ones completed.