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. Elevating the affected leg is an important intervention for reducing swelling and promoting venous return, which can help alleviate discomfort and prevent further complications.
B. Placing cold compresses on the edematous area may provide temporary relief but is not a standard intervention for deep-vein thrombosis and could potentially harm tissue if applied for too long.
C. Restricting the client to 1 L of fluid per day is inappropriate, as adequate hydration is essential for maintaining good venous health and preventing further complications.
D. Maintaining the client on bed rest is not necessary; while rest is important, early ambulation is encouraged to promote circulation and prevent further clot formation unless contraindicated.
Correct Answer is B
Explanation
Rationale:
A. Offering flavored gelatin can provide some hydration, but it does not provide sufficient electrolytes necessary for rehydration in gastroenteritis.
B. Initiating oral rehydration therapy for the toddler is essential in treating dehydration caused by infectious gastroenteritis. Oral rehydration solutions contain the right balance of electrolytes and fluids to replenish losses.
C. While chicken broth may provide some fluid and salt, it is not as effective as a specific oral rehydration solution tailored for children with gastroenteritis.
D. The BRAT diet (bananas, rice, applesauce, and toast) is no longer recommended as the primary diet for children with gastroenteritis, as it does not provide adequate nutrition or electrolytes.