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 D
Explanation
Rationale:
A. Decreased cholesterol is not a primary effect of chlorpromazine; the medication is primarily used for psychiatric conditions, not lipid management.
B. While chlorpromazine may have sedative effects that could impact blood pressure, decreased blood pressure is not a direct indicator of its effectiveness in treating psychiatric symptoms.
C. Decreased esophageal reflux is not a relevant effect of chlorpromazine, as it is primarily used for managing psychotic symptoms.
D. Decreased hallucinations is a direct indication of the medication's effectiveness in treating conditions such as schizophrenia or other psychotic disorders, as chlorpromazine is an antipsychotic medication.
Correct Answer is C
Explanation
Rationale:
A. The reason for the medication error should not be documented in the client's medical record due to potential legal implications; such information belongs in the incident report instead.
B. Documentation of notification to the pharmacist is relevant for the incident report but is not appropriate for the client's medical record.
C. The time the medication was given is an important detail that should be documented in the client's medical record as it affects the client's treatment and future medication administration.
D. Documenting the completion of the incident report should be done in the facility's quality assurance system, not in the client’s medical record.