The home health nurse observes a client self-administering an epinephrine injection using an auto-injector pen.

Which client action requires intervention by the nurse?

Administers onto the ﬂeshy outer thigh.

Inserts the injection pen through clothing.

Cleanses the injection pen for re-use.

Cleans the injector pen for re-use.

Answer and Explanation

The Correct Answer is C

A. Administers onto the ﬂeshy outer thigh: This is the recommended site for epinephrine auto-injection because it allows for quick absorption into the bloodstream. The outer thigh is a large muscle area, which helps in the rapid distribution of the medication.

B. Inserts the injection pen through clothing: It is generally acceptable to inject epinephrine through clothing in an emergency situation. This practice ensures that there is no delay in administering the life-saving medication, which is crucial during an anaphylactic reaction.

C. Cleanses the injection pen for re-use: Epinephrine auto-injectors are designed for single use only. Reusing the pen can lead to contamination and reduced effectiveness of the medication. It is important to dispose of the used injector properly and obtain a new one for future use.

D. Holds the pen in place after injection: Holding the pen in place for a few seconds after injection ensures that the full dose of medication is delivered. This practice helps in maximizing the effectiveness of the treatment during an anaphylactic emergency.

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Correct Answer is C

Explanation

Restless legs syndrome is a condition that causes an uncomfortable sensation in the legs and an uncontrollable urge to move them. Melatonin is a natural hormone that helps regulate the sleep-wake cycle and can be used as a sleep aid. Therefore, when evaluating the eﬀectiveness of melatonin in an older adult client with restless legs syndrome, the nurse should assess the client's sleep patterns to determine if the herb is improving their ability to fall and stay asleep.

Assessing anxiety level (a) may be useful in other contexts, but it is not directly relevant to evaluating the eﬀectiveness of melatonin for restless legs syndrome. Observing for peripheral edema (b) and palpating pedal pulse volume (d) are important assessments in clients with peripheral vascular disease or other circulatory disorders, but they are not directly related to restless legs syndrome or the use of melatonin.

A. A coronary artery bypass procedure was performed in 1995. B. Suﬀered with depression following death of spouse in 1999. C. Digoxin and furosemide daily since 1996. D. A Colonoscopy was performed for routine screening six months ago.

Correct Answer is C

Explanation

Digoxin is a medication commonly used to treat heart failure by strengthening the heart's contractions and slowing down the heart rate. However, it can also cause nausea, vomiting, and loss of appetite, especially when levels in the body are too high. Furosemide is a diuretic medication that helps to remove excess ﬂuid from the body, which is often necessary in heart failure. However, it can also cause electrolyte imbalances, such as low potassium levels, which can contribute to nausea and vomiting.

Therefore, in a client with heart failure who is experiencing these symptoms, it is important to assess their medication regimen, including dosages and serum levels, to ensure that they are not experiencing medication side eﬀects or toxicity.

Adjustments may need to be made to the client's medication regimen to manage symptoms eﬀectively and prevent further complications. Options (a), (b), and (d) do not have as direct a correlation to the current symptoms and would not have the same level of significance when planning care for this client.

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The home health nurse observes a client self-administering an epinephrine injection using an auto-injector pen. Which client action requires intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client with restless legs syndrome begins taking melatonin at bedtime. When evaluating the eﬀectiveness of the herb which client assessment should the nurse complete?

Correct Answer is C

Explanation

An elderly client with heart failure comet to the emergency room because of nausea, vomiting, and anorexia. Based on the client’s signs and symptoms, which data from the medical history has the most significance when planning this client’s care?

Correct Answer is C

Explanation

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The home health nurse observes a client self-administering an epinephrine injection using an auto-injector pen. Which client action requires intervention by the nurse?

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Which assessment data indicated to the nurse that a client is having an anaphylactic reaction to a medication?

The nurse assesses a client with intermittent claudication who is receiving pentoxifylline. Which assessment should the nurse perform to determine the eﬀectiveness of the medication?

The home health nurse observes a client self-administering an epinephrine injection using an auto-injector pen.

Which client action requires intervention by the nurse?