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.

Holding the pen in place for several seconds after injection

Cleans the injector pen for re-use.

None

Answer and Explanation

The Correct Answer is D

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 B

Explanation

Metformin is a medication that can aﬀect kidney function. Since contrast dye used in CT scans is processed through the kidneys, it is important for the nurse to follow up on the client’s use of metformin before the CT scan with contrast. The client may need to temporarily stop taking metformin before and after the procedure to prevent any potential harm to their kidneys.

A. Increased urinary clearance of the multiple medications has produced diuresis and lowered blood pressure. B. The synergetic eﬀect of the multiple medication has resulted in drug toxicity and resulting hypotension. C. The antagonistic interaction among the various blood pressure medications has reduced their eﬀectiveness. D. The additive eﬀect of multiple medications has caused the blood pressure to drop too low.

Correct Answer is D

Explanation

The client is experiencing syncope (fainting) due to a drop in blood pressure to 70/40 mm Hg, which is too low. This suggests that the client's blood pressure medications are reducing their blood pressure too much, resulting in hypotension. The rationale for the nurse's decision to hold the client's scheduled antihypertensive medications is to prevent further hypotension and allow the client's blood pressure to stabilize at a safer level.

Option a is incorrect because diuresis (increased urine output) is not a likely cause of the client's hypotension.

Option b is incorrect because the client's symptoms suggest hypotension due to reduced blood pressure, rather than drug toxicity.

Option c is incorrect because the antagonistic interaction among blood pressure medications would result in reduced eﬀectiveness but would not necessarily cause hypotension.

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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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?