A nurse is reinforcing teaching about receiving epinephrine as an emergency intervention for anaphylaxis. Which of the following information should the nurse reinforce with the client?

Epinephrine relaxes the bronchioles and counteracts the effect of histamine

Epinephrine should be given along with a beta blocker.

Epinephrine should be administered intranasally

Epinephrine causes a decrease in blood pressure

Answer and Explanation

The Correct Answer is A

A. Epinephrine relaxes the bronchioles and counteracts the effect of histamine: Epinephrine is the first-line treatment for anaphylaxis because it rapidly relaxes bronchial smooth muscles, reducing airway constriction, and counteracts histamine's effects, which include vasodilation, edema, and hypotension. This helps restore breathing and circulation.

B. Epinephrine should be given along with a beta blocker: Administering epinephrine with a beta blocker is dangerous because beta blockers can reduce the effectiveness of epinephrine and may worsen bronchospasm. Beta blockers are not recommended during acute management of anaphylaxis.

C. Epinephrine should be administered intranasally: Epinephrine is typically administered intramuscularly (IM), usually into the thigh, during anaphylactic emergencies for rapid absorption. Intranasal administration is not effective for treating life-threatening systemic allergic reactions.

D. Epinephrine causes a decrease in blood pressure: Epinephrine actually increases blood pressure by causing vasoconstriction. This counters the dangerous hypotension that occurs during anaphylaxis, helping to stabilize cardiovascular function quickly.

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Correct Answer is A

Explanation

A. Demonstrate to the client how to use the signaling device: Teaching the client how to use the call light is the priority because it ensures they can easily ask for assistance, especially with limited mobility. Immediate access to help reduces the risk of falls, injury, and delays in meeting urgent needs.

B. Explain the facility's meal schedule: While it is important for the client to know when meals are served, this information does not impact their immediate safety or ability to get assistance when needed, making it a lower priority than teaching about the call light.

C. Demonstrate to the client how to use the television: Teaching about the television promotes comfort but is nonessential for safety or urgent needs. Comfort measures can be addressed after critical safety interventions have been completed.

D. Explain the medication administration schedule: Understanding medication schedules is important for client education and adherence, but ensuring the ability to call for help is more immediately critical, especially in a client with limited mobility.

A. Ringing in the ears B. Black, tarry stools C. Fine hand tremors D. Diarrhea

Correct Answer is B

Explanation

A. Ringing in the ears: Ringing in the ears (tinnitus) is not a common adverse effect of enoxaparin. It is typically associated with medications like aspirin or other salicylates, not low-molecular-weight heparins like enoxaparin.

B. Black, tarry stools: Black, tarry stools are a sign of gastrointestinal bleeding, which is a serious potential adverse effect of anticoagulant medications like enoxaparin. Clients taking enoxaparin should be instructed to report this symptom immediately, as it could indicate internal bleeding.

C. Fine hand tremors: Fine hand tremors are not a known adverse effect of enoxaparin. They are more commonly associated with other medications, such as certain psychiatric drugs or neurologic conditions.

D. Diarrhea: Diarrhea is not a common adverse effect of enoxaparin. While gastrointestinal symptoms can occur with many medications, it is not a primary concern or indication for discontinuing enoxaparin.

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A nurse is reinforcing teaching about receiving epinephrine as an emergency intervention for anaphylaxis. Which of the following information should the nurse reinforce with the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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