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","D","E"]
Explanation
Rationale:
A. Polyuria is not typically associated with immobility; instead, immobility can lead to urinary retention.
B. Contractures of the extremities occur due to prolonged immobility, leading to shortening of muscles and tendons.
C. Diarrhea is not a common complication of immobility; constipation is more frequently seen due to decreased mobility.
D. Crackles in the lungs can develop due to stasis of secretions and respiratory complications related to immobility.
E. Pressure ulcers develop from prolonged pressure on the skin due to immobility, especially over bony prominences.
Correct Answer is D
Explanation
Rationale:
A. Encouraging friends and family to visit the child is not appropriate due to the risk of infections, as the child has a severely compromised immune system.
B. A low-protein diet is not indicated; children with leukemia often require adequate nutrition to support their health.
C. Collecting a daily urine specimen for proteinuria is not specifically indicated for this condition; the focus should be on infection prevention.
D. Withholding the varicella vaccine is essential because live vaccines are contraindicated in immunocompromised patients due to the risk of severe infections.