# Situation: The nurse works in the critical care area of an emergency department that receives acutely ill adults. None of the clients below is pregnant. Another client with a hypertensive emergency and acute heart failure is started on sodium nitroprusside. Which nursing action is correct?

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> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: The nurse works in the critical care area of an emergency department that receives acutely ill adults. None of the clients below is pregnant.

Another client with a hypertensive emergency and acute heart failure is started on sodium nitroprusside. Which nursing action is correct?

## 보기

1. Check the blood pressure with an arm cuff every hour
2. Shield the infusion bag from light **✔ 정답**
3. Flush the line with saline whenever the pump alarms
4. Give the first dose as a slow undiluted intravenous push

**정답: 2**

## 해설

Sodium nitroprusside breaks down in light, so the bag is protected with an opaque cover. It must be diluted and given only by infusion pump with continuous arterial blood pressure monitoring, because it can cause sudden severe hypotension; prolonged or high-dose use can cause cyanide toxicity.

## 심화 해설

Core principle Sodium nitroprusside is a rapid-acting arterial and venous vasodilator used for hypertensive emergencies and acute heart failure, but its safe administration depends on protecting the drug from light, diluting it properly, and monitoring blood pressure continuously. The correct nursing action is to shield the infusion bag from light.

Why light protection is essential Nitroprusside is a photolabile compound. When the solution is exposed to light, the drug undergoes photodegradation, which causes two clinically important problems. First, the active drug loses potency, so the patient may not receive the intended antihypertensive effect. Second, and more dangerous, light-induced breakdown releases cyanide and nitric oxide from the nitroprusside molecule. Exposing the infusion to white or blue light accelerates degradation, whereas red light does not produce the same effect [3]. Therefore, the infusion bag and tubing should be wrapped in an opaque cover to maintain drug stability and minimize cyanide formation.

Stability in protected containers When the solution is kept in light-protected glass or plastic containers, nitroprusside remains stable in common diluents such as 5% dextrose, normal saline, and lactated Ringer’s solution [4]. Simulated infusion studies show no decrease in delivered potency for up to 24 hours when the system is protected from light [4]. This supports the practice of preparing the infusion in a light-shielded bag and using opaque or light-resistant tubing.

Why the other options are incorrect

| Option | Reason it is incorrect |
| --- | --- |
| 1. Check blood pressure with an arm cuff every hour | Hourly cuff checks are insufficient. Nitroprusside can cause sudden, profound hypotension within minutes. Continuous intra-arterial blood pressure monitoring is recommended during infusion. |
| 3. Flush the line with saline whenever the pump alarms | Flushing the line can deliver a bolus of concentrated nitroprusside, causing dangerous hypotension. When the pump alarms, the nurse should troubleshoot the occlusion or air-in-line without flushing the drug line. |
| 4. Give the first dose as a slow undiluted intravenous push | Nitroprusside must never be given by IV push. It requires dilution and administration only by a controlled infusion pump with continuous hemodynamic monitoring. |

Cyanide toxicity and monitoring Nitroprusside is metabolized to cyanide, which is normally converted to thiocyanate and excreted. However, prolonged infusion, high doses, or renal impairment can lead to cyanide accumulation and toxicity . Signs of cyanide toxicity include altered mental status, metabolic acidosis, tachyphylaxis to the drug’s effect, and cardiovascular collapse. The FDA labeling change emphasized this pharmacokinetic risk . Key point! Co-infusion of sodium thiosulfate provides a sulfur donor that helps convert cyanide to the less toxic thiocyanate, a preventive strategy sometimes used in practice .

Clinical application for the critical care nurse When caring for a client receiving nitroprusside, the nurse should verify that the solution is diluted, the infusion pump is programmed correctly, the bag and tubing are shielded from light, and arterial blood pressure is monitored continuously. Watch out! Never flush the line or change the infusion rate abruptly without considering the risk of a bolus effect. The light-protection step is a simple but non-negotiable safety measure that directly prevents both loss of drug potency and increased cyanide exposure.References (research sources)

- [3]Photodegradation of sodium nitroprusside: biologic activity and cyanide release.Research articleArnold WP, Longnecker DE, Epstein RM (1984) · DOI: 10.1097/00000542-198409000-00004

- [4]In vitro stability of sodium nitroprusside solutions for intravenous administration.Research articleMahony C, Brown JE, Stargel WW, Verghese CP, Bjornsson TD (1984) · DOI: 10.1002/jps.2600730636

## 임상 시나리오

Nitroprusside Infusion SafetyLight protection and monitoring priorities
Sodium nitroprusside is a photolabile vasodilator; exposure to light causes photodegradation that reduces drug potency and releases cyanide. Always shield the infusion bag and tubing with an opaque cover.

Administer only as a diluted continuous infusion via an infusion pump. Monitor blood pressure continuously with an arterial line, not intermittent cuff checks, because sudden severe hypotension can occur.

CautionNever flush the line during a pump alarm; this can deliver a concentrated bolus and cause dangerous hypotension. Prolonged or high-dose use increases cyanide toxicity risk.

## 핵심 개념

- **Sodium nitroprusside** — Rapid-acting arterial and venous vasodilator used for hypertensive emergencies and acute heart failure.
- **Photodegradation** — Light-induced breakdown of nitroprusside that reduces potency and releases cyanide and nitric oxide.
- **Cyanide toxicity** — Dangerous accumulation of cyanide from prolonged or high-dose nitroprusside exposure.
- **Arterial line monitoring** — Continuous intra-arterial blood pressure monitoring required during nitroprusside infusion.
- **Infusion pump** — Required delivery device for nitroprusside to ensure precise, controlled dosing.

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