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 C
Explanation
Rationale:
A. Concerns about participation in team sports may indicate a desire for improved lung function but do not directly necessitate the use of a high-frequency chest compression vest.
B. Discomfort during nebulizer treatments may warrant alternative therapies, but it is not a direct indication for a high-frequency chest compression vest.
C. A small amount of mucus after percussion therapy suggests inadequate airway clearance, which may prompt the need for more effective techniques, such as the high-frequency chest compression vest, to facilitate mucus clearance and improve lung function.
D. A fever indicates a potential infection and requires further assessment but does not directly suggest the need for a high-frequency chest compression vest.
Correct Answer is ["B","C","D"]
Explanation
Rationale:
A. Assessing a client requires clinical judgment and should not be delegated to an AP.
B. Accompanying a client to occupational therapy is a task that can be safely assigned to an AP as it does not require clinical judgment.
C. Checking the position of a client in soft wrist restraints is a routine task that can be assigned to an AP as long as the AP has been trained in restraint protocols.
D. Sitting with a client who has alcohol use disorder (5 days after their last drink) is a task that an AP can perform, especially if the client does not require close monitoring for medical complications such as delirium tremens.
E. Setting limits with a client requires therapeutic communication skills and clinical judgment, so this should not be delegated to an AP.