A nurse is caring for a client who is at risk for anaphylaxis due to bee stings. When reinforcing teaching about the use of an automatic epinephrine injector, which of the following actions is the priority?

Review the signs of anaphylaxis with the client.

Instruct the client to store the injector at room temperature.

Inform the client to seek medical attention following administration of the injection.

Have the client perform a return demonstration of the equipment.

Answer and Explanation

The Correct Answer is C

The correct answer is c. Inform the client to seek medical attention following administration of the injection.

Choice A reason: Reviewing the signs of anaphylaxis with the client is important, but it’s not the priority. The client must first know what to do in case of an emergency.

Choice B reason: Instructing the client to store the injector at room temperature is a part of the storage instructions, but it’s not the immediate action to take during an anaphylactic reaction.

Choice C reason: This is the priority because anaphylaxis is a potentially life-threatening condition and even after administering epinephrine, it’s crucial to seek immediate medical attention.

Choice D reason: Having the client perform a return demonstration of the equipment is a good teaching method, but it’s not the immediate action to take when an anaphylactic reaction occurs.

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Correct Answer is C

Explanation

Red streaks along the incision. This is a possible sign of infection and should be reported to the healthcare provider. A temperature of 37.2°C (99°F) is within the normal range and does not require reporting. Serosanguineous drainage at the incision site is normal within the first few days postoperatively. Hypoactive bowel sounds in all four quadrants can indicate ileus, which is a possible complication following abdominal surgery, but it is not an immediate concern and can be monitored unless other symptoms arise.

Choice A: A temperature of 37.2°C (99°F) is within the normal range and does not require reporting.

Choice B: Serosanguineous drainage at the incision site is normal within the first few days postoperatively.

Choice D: Hypoactive bowel sounds in all four quadrants can indicate ileus, which is a possible complication following abdominal surgery, but it is not an immediate concern and can be monitored unless other symptoms arise.

A. Have an assistive personnel feed the client. B. Apply foam handles to the client's eating utensils. C. Obtain a referral for physical therapy. D. Ask the provider for a prescription for a pureed diet.

Correct Answer is B

Explanation

Apply foam handles to the client's eating utensils. This intervention can help the client grip the utensils better and improve their ability to eat.

Reasons why the other options are not answers:

Option A: Having an assistive personnel feed the client may decrease the client's autonomy.

Option C: Obtaining a referral for physical therapy may be helpful but does not address the immediate issue of difficulty with eating.

Option D: Asking the provider for a prescription for a pureed diet may not be necessary or desirable at this time.

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A nurse is caring for a client who is at risk for anaphylaxis due to bee stings. When reinforcing teaching about the use of an automatic epinephrine injector, which of the following actions is the priority?

Nursing Test Bank

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