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 A
Explanation
Rationale
A. Contact precautions are appropriate for MRSA to prevent the transmission of bacteria through direct or indirect contact with the infected area. This includes wearing gloves and gowns when caring for the client and ensuring proper hand hygiene.
B. Droplet precautions are used for pathogens that are spread through respiratory droplets, which is not applicable to MRSA.
C. Protective equipment is typically used for immunocompromised patients to prevent infections, but it is not the standard for MRSA.
D. Airborne precautions are necessary for diseases that spread through airborne particles, which does not include MRSA.
Correct Answer is C
Explanation
Rationale:
A. Withholding the next dose of warfarin may not be necessary at this point, as the INR is elevated but not critically high. Monitoring is essential, but vitamin K administration is indicated if the INR exceeds therapeutic levels significantly.
B. Withholding the heparin infusion is not appropriate since the aPTT is critically elevated, indicating that the client is at risk for bleeding. Heparin should be adjusted, but not entirely withheld without further evaluation.
C. Preparing to administer vitamin K is appropriate because the INR is elevated (1.8), indicating an increased risk for bleeding. Vitamin K is used to reverse the effects of warfarin.
D. Preparing to administer alteplase (a thrombolytic) is unnecessary and inappropriate in this situation, as the client is already receiving anticoagulation therapy with heparin and warfarin.