Immediately after receiving an injection of bupivacaine (Marcaine), the client becomes restless and nervous and reports a feeling of impending doom. Which of the following actions by the nurse is appropriate?
1. Ask the client to explain these feelings.
2. Reassure the client that it is normal to feel restless before a procedure.
3. Assess the client’s vital signs.
4. Administer epinephrine.
The nurse should assess the client’s vital signs because there is a likelihood of having a reaction to the bupivacaine. If the client’s vital signs are abnormal, immediate intervention may be necessary.
Although the nurse may ask the client to continue to describe feelings, this is not likely to be a psychosocial reaction. Simple reassurance is inappropriate in most clinical situations and can be dangerous if physiologic causes of restlessness are overlooked. The nurse should not administer epinephrine until vital signs have been assessed.
CN: Pharmacological and parenteral therapies; CL: Synthesize
小编寄语：Efforts to create the strength, attitude determines altitude.努力造就实力，态度决定高度！