A nurse is monitoring a client who received epinephrine for angioedema after a first dose of losartan. Which of the following data indicates a therapeutic response to the epinephrine?
The client tolerates a second dose of medication with no greater than 1 peripheral edema.
Respirations are unlabored.
Client reports decreased groin pain of 3 on a 1 to 10 scale.
The client's blood pressure when arising from resting position is at premedication levels.
The Correct Answer is B
A) The client tolerates a second dose of medication with no greater than 1 peripheral edema:
This does not directly indicate a therapeutic response to epinephrine for angioedema. Angioedema primarily involves swelling of deeper layers of the skin, often around the eyes and lips, and sometimes the throat, which can cause breathing difficulties. Tolerating a second dose of medication with minimal peripheral edema does not specifically address the acute respiratory effects of angioedema.
B) Respirations are unlabored:
This is the correct answer. Angioedema can cause swelling in the airways, leading to difficulty breathing. Epinephrine is used to reduce this swelling and improve airway patency. Unlabored respirations indicate that the airway is not obstructed, which means the epinephrine has successfully alleviated the swelling causing the angioedema.
C) Client reports decreased groin pain of 3 on a 1 to 10 scale:
Decreased groin pain is not relevant to the treatment of angioedema with epinephrine. Pain relief in the groin area does not indicate a therapeutic response to epinephrine, which is primarily used to address airway and anaphylactic symptoms.
D) The client's blood pressure when arising from resting position is at premedication levels:
While epinephrine can affect blood pressure, the main concern with angioedema is airway obstruction rather than blood pressure control. Normalizing blood pressure does not specifically indicate that the epinephrine has successfully treated the angioedema and improved the client's respiratory status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Utilitarianism: Utilitarianism focuses on the greatest good for the greatest number of people. In this scenario, the nurse's decision not to administer the pain medication is not based on maximizing overall benefit but rather on avoiding harm to the individual client.
B) Non-maleficence: Non-maleficence is the ethical principle of doing no harm. The nurse's decision not to administer the pain medication is rooted in the desire to avoid causing harm to the client by potentially hastening their death.
C) Fidelity: Fidelity refers to the obligation to fulfill commitments and responsibilities. While important, fidelity is not directly relevant to the nurse's decision in this scenario.
D) Veracity: Veracity refers to truthfulness and honesty. While honesty is crucial in communicating with the client and their family about their condition and care, it is not the primary ethical principle guiding the nurse's decision in this situation.
Correct Answer is C
Explanation
A. Contact the provider for further orders:
Contacting the provider for further orders might delay the administration of blood, which is crucial in situations where there is an urgent need, such as severe bleeding or anemia. Given that the unit of blood available is type O negative, which is universally compatible with most recipients in emergency situations, waiting for further orders could jeopardize the client's health.
B. Complete an incident report:
There is no incident or error that occurred in this situation. Using type O negative blood for a recipient with type A positive blood is an accepted practice in emergencies, and therefore, does not warrant the completion of an incident report.
C. Administer the blood as ordered:
Type O negative blood can be safely administered to recipients with any blood type in emergency situations. Since the client requires blood, and the unit available is type O negative, which is universally compatible, administering the blood as ordered is the appropriate action to ensure timely treatment.
D. Notify the blood bank:
Notifying the blood bank is unnecessary in this situation. The nurse has a unit of type O negative blood on hand, which is appropriate for immediate administration to the client with type A positive blood. There's no need to inform the blood bank as the blood is compatible and can be safely administered.
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