A nurse is assessing a client after administering epinephrine for an anaphylactic reaction. Which of the following findings should the nurse identify as an adverse effect of this medication?
Hypotension
Report of tinnitus
Report of chest pain
Ecchymosis
The Correct Answer is C
- A. Hypotension is not an adverse effect of epinephrine, but rather a sign of anaphylaxis that epinephrine can help to reverse by causing vasoconstriction and increasing blood pressure.
- B. Report of tinnitus is not an adverse effect of epinephrine, but rather a symptom of aspirin toxicity, which can occur in some clients who take aspirin for allergic reactions.
- C. Report of chest pain is an adverse effect of epinephrine, as it can cause cardiac dysrhythmias, angina, and myocardial ischemia by increasing the heart rate and oxygen demand of the myocardium.
-D. Ecchymosis is not an adverse effect of epinephrine, but rather a sign of bleeding disorders or trauma that can cause bruising under the skin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Implement fall precautions for the client.
- A. Implement fall precautions for the client. This is correct because risperidone can cause orthostatic hypotension, which can increase the risk of falls and injuries. The nurse should advise the client to change positions slowly, avoid alcohol and dehydration, and use assistive devices as needed.
- B. Monitor the client's thyroid function. This is incorrect because risperidone does not affect thyroid function. The nurse should monitor the client's thyroid function if they are taking lithium, which can cause hypothyroidism.
- C. Place the client on a fluid restriction. This is incorrect because risperidone does not cause fluid retention or overload. The nurse should encourage adequate fluid intake and monitor the client's fluid balance.
- D. Discontinue the medication if hallucinations occur. This is incorrect because hallucinations are a symptom of schizophrenia, not a side effect of risperidone. The nurse should not discontinue the medication abruptly, as this can cause withdrawal symptoms and relapse of psychosis. The nurse should assess the client's response to the medication, report any adverse effects, and adjust the dosage as prescribed.
Correct Answer is C
Explanation
Choice A rationale:
Tightening the tubing connections may be necessary if there is a leak in the ventilator system, but it does not address the high-pressure alarm issue. The nurse needs to address the immediate alarm situation first.
Choice B rationale:
Requesting insertion of a tracheostomy tube is not the appropriate action for a high-pressure alarm on the ventilator. Tracheostomy tube insertion is a significant procedure that is not indicated solely based on a high-pressure alarm.
Choice C rationale:
Suctioning the client's airway is the correct action for a high-pressure alarm on the ventilator. The alarm indicates an obstruction in the airway, and suctioning can help clear any secretions or blockages, allowing the client to breathe more effectively.
Choice D rationale:
Looking for a leak in the tube's cuff may be necessary if the high-pressure alarm persists after suctioning and checking connections. Identifying and repairing any leaks can prevent further issues with ventilation. However, immediate action should be taken to clear the airway first, as indicated by suctioning.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today