A nurse in an acute care facility is collecting data from a client who has received the meningococcal conjugate vaccine.
The nurse should monitor the client for which of the following findings as an adverse effect of the vaccine?

Choice A rationale:

Docusate sodium is a stool softener and does not have a direct effect on blood pressure. It is generally safe for individuals with hypertension.

Choice B rationale:

Pseudoephedrine is a decongestant that can raise blood pressure or interfere with the effectiveness of some prescribed blood pressure medications. Therefore, it is contraindicated for clients with hypertension.

Choice C rationale:

Omeprazole is a proton pump inhibitor used to decrease stomach acid. It does not have a significant impact on blood pressure and is generally safe for individuals with hypertension.

Choice D rationale:

Guaifenesin is an expectorant used to thin mucus in the air passages. It does not have a significant impact on blood pressure and is generally safe for individuals with hypertension.

Choice A rationale:

Asking the client to demonstrate dose delivery can be part of patient education and helps ensure that the client understands how to use the PCA device. This action does not require intervention.

Choice B rationale:

The nurse administering a PCA dose for the client requires intervention. PCA stands for “Patient-Controlled Analgesia,” meaning that only the patient should administer doses to themselves. This prevents overdosing and ensures that pain medication is administered according to the patient’s needs.

Choice C rationale:

Reassuring the client that the PCA device will not cause an overdose is appropriate because PCA devices are designed with safety measures to prevent overdosing.

Choice D rationale:

Monitoring for oversedation is an important part of care for a client using a PCA device. This action does not require intervention.