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?
Report of chest pain
Hypotension
Ecchymosis
Report of tinnitus
The Correct Answer is A
Rationale:
A. A report of chest pain is an adverse effect of epinephrine, which can increase myocardial oxygen demand and cause angina or myocardial ischemia.
B. Hypotension is not a common effect after administering epinephrine; it typically causes hypertension due to vasoconstriction.
C. Ecchymosis is not a known adverse effect of epinephrine and may be related to other factors.
D. Tinnitus is not a recognized adverse effect of epinephrine and does not commonly occur after administration.
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Correct Answer is B
Explanation
Rationale:
A. Surgical asepsis (sterile technique) should be used for suctioning to prevent infection, not medical asepsis.
B. Applying suction for no longer than 10 seconds is appropriate to prevent hypoxia and trauma to the airway.
C. Advancing the catheter 2 cm after resistance is met is not advised; the catheter should not be forced beyond resistance to avoid injury.
D. The catheter should not be withdrawn if the client begins coughing; instead, it indicates the need for suctioning. If coughing occurs, the nurse should ensure the patient can breathe and may need to suction carefully.
Correct Answer is D
Explanation
Rationale:
A. A dry cough is not a common adverse effect associated with ibuprofen and is more related to respiratory issues.
B. An increase in urine output is not a typical adverse effect of ibuprofen; rather, it may indicate a different condition.
C. Muscle stiffness is a symptom of juvenile idiopathic arthritis itself and not specifically an adverse effect of ibuprofen.
D. Asking about stomach pain or bloody stools is crucial as ibuprofen can cause gastrointestinal irritation, ulcers, or bleeding, which are serious adverse effects of long-term use.