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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. The nurse places the client on airborne precautions: This is appropriate, as measles is transmitted via airborne particles. B. The nurse has the client wear a mask for transport to radiology: This is correct. A surgical mask minimizes the risk of spreading airborne pathogens during transport. C. The nurse wears an N95 respirator when performing client care: Correct. An N95 respirator is necessary for protection against airborne diseases like measles. D. The nurse ensures the client's room maintains a positive airflow: This is incorrect and requires intervention. Clients with airborne infections like measles must be placed in negative pressure rooms, which prevent contaminated air from escaping into other areas. Positive airflow increases the risk of transmission to others.

A. "I would like to talk to you about the unit policies regarding break time." B. "If you continue to take a long lunch break, I will have to report this to the nurse manager." C. "Have you thought about how your extended lunch breaks affect the other members of our team?" D. "Did you inform the other members of your team about when you left and returned from break?"

Correct Answer is A

Explanation

A is correct because it is a direct and respectful way of addressing the issue with the nurse who is violating the unit policies. It also opens up a dialogue for possible solutions and feedback.
B is incorrect because it is a threatening and punitive statement that does not address the root cause of the problem or offer any constructive feedback.
C is incorrect because it is a passive-aggressive and guilt-inducing statement that does not clearly communicate the expectations or consequences of violating the unit policies.
D is incorrect because it is an irrelevant and deflecting statement that does not address the issue of taking an extended amount of time for break.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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