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 A

Explanation

The correct answer is choice A. Washing hands after leaving the room is an important infection control measure for individuals who come into contact with clients on contact precautions. Choice B is incorrect because gowns are only necessary when there is a risk of contact with the client's body fluids. Choice C is incorrect because gloves should not be reused. Choice D is incorrect because the client should not leave the room while on contact precautions. Choice B is not correct because gowns are only necessary when there is a risk of contact with the client's body fluids. Choice C is not correct because gloves should not be reused. Choice D is not correct because the client should not leave the room while on contact precautions.

A. Temperature 37.3° C (99.1° F) B. WBC Count 9,000/mm3 C. Changed mental status D. Diminished reflexes

Correct Answer is C

Explanation

A bladder infection can lead to confusion or other changes in mental status, especially in older adults. A normal temperature and WBC count do not necessarily indicate a bladder infection. Diminished reflexes are not typically associated with a bladder infection.

A: A temperature of 37.3° C (99.1° F) is within the normal range and does not necessarily indicate a bladder infection.

B: A WBC count of 9,000/mm3 is within the normal range and does not necessarily indicate a bladder infection.

D: Diminished reflexes are not typically associated with a bladder infection.

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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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