A nurse is collecting data from a client who is taking dimenhydrinate to treat motion sickness. Which of the following findings is an adverse effect of this medication?

A. The nurse monitors the client for over sedation. Monitoring for over sedation is an essential nursing responsibility when caring for a client using a patient-controlled analgesia (PCA) device. Opioid medications used in PCAs can cause respiratory depression, drowsiness, and decreased level of consciousness, so frequent assessments are necessary to ensure client safety.

B. The nurse reassures the client that the PCA device will not cause an overdose. PCA devices are programmed to deliver a controlled dose of medication at set intervals, reducing the risk of overdose. Educating the client about this built-in safety feature helps alleviate anxiety and encourages appropriate pain management. However, the nurse should also instruct the client to report symptoms of over sedation or inadequate pain relief.

C. The nurse asks the client to demonstrate dose delivery. Encouraging the client to demonstrate how to use the PCA device ensures they understand how to properly self-administer medication. This reinforces client education, promotes effective pain management, and minimizes unnecessary delays in pain relief due to improper use.

D. The nurse administers a PCA dose for the client. Only the client should press the PCA button to self-administer medication. This prevents accidental overdose or over sedation that could occur if the client is too sedated to recognize their own need for pain relief. If the client is unable to use the PCA properly, alternative pain management strategies should be considered, rather than allowing a nurse or family member to press the button.

• Shortness of breath. The client is experiencing respiratory distress, which could indicate a severe allergic reaction (anaphylaxis). Immediate intervention is needed to prevent airway compromise and respiratory failure.
• Intercostal retractions. Retractions occur when breathing is labored, suggesting airway obstruction or bronchoconstriction. This is a sign of worsening respiratory distress, requiring urgent medical attention.
• Wheezing auscultated throughout lung fields. Wheezing suggests bronchospasm, which is common in anaphylaxis and asthma attacks. The presence of diffuse wheezing indicates that the airways are narrowing, making breathing more difficult.
• Diffuse, raised rash present on trunk. A new-onset rash following antibiotic administration raises suspicion for anaphylaxis or a severe allergic reaction. Immediate treatment with antihistamines and corticosteroids may be required.
• Respiratory rate 30/min. The increased respiratory rate indicates that the client is compensating for airway constriction and hypoxia. This is an early warning sign of impending respiratory failure if not treated promptly.
• Blood pressure 90/55 mmHg. The drop in blood pressure suggests anaphylactic shock, where vasodilation and fluid leakage from capillaries lead to hypotension. Immediate administration of epinephrine is necessary to prevent cardiovascular collapse.
• Oxygen saturation 91% on room air. A decrease in oxygen saturation indicates impaired gas exchange, likely due to airway swelling and bronchospasm. Supplemental oxygen therapy should be provided to prevent further desaturation.