A 55-year-old client post-cardiac surgery is receiving continuous norepinephrine infusion titrated to maintain a mean arterial pressure (MAP) greater than 65 mmHg. The client's current vital signs are BP 80/40 mmHg, HR 110 bpm, RR 20 bpm, SpO2 96%. Peripheral pulses are weak, and capillary refill is 4 seconds. What is the nurse's priority action?

Question: A 55-year-old client post-cardiac surgery is receiving continuous norepinephrine infusion titrated to maintain a mean arterial pressure (MAP) greater than 65 mmHg. The client's current vital signs are BP 80/40 mmHg, HR 110 bpm, RR 20 bpm, SpO2 96%. Peripheral pulses are weak, and capillary refill is 4 seconds. What is the nurse's priority action?

Answer options: ✅ Increase the norepinephrine infusion rate as per protocol.

• Administer a 250 mL bolus of 0.9% sodium chloride.
• Notify the healthcare provider immediately about the client's condition.
• Assess urine output and initiate fluid restriction.

Correct answer: Increase the norepinephrine infusion rate as per protocol.

Explanation: The client's low blood pressure (MAP = (80 + 2*40)/3 = 53.3 mmHg) indicates inadequate perfusion, falling below the target of 65 mmHg. The priority is to adjust the norepinephrine infusion, which is a potent vasoconstrictor, to improve systemic vascular resistance and blood pressure as per the standing protocol. Although notifying the physician is important, acting on the standing order is the immediate intervention.