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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Atorvastatin is a medication used to lower cholesterol levels in the blood. One of its side effects is muscle damage, which can result in an increase in serum creatine phosphokinase (CK) levels. Creatine phosphokinase is an enzyme found in muscles, and when muscles are damaged, CK is released into the bloodstream. Therefore, an increased serum CK level indicates muscle damage, and the nurse should assess the client for muscle tenderness or weakness, which are symptoms of this side effect. Nausea and vomiting, excessive bruising, and peripheral edema are not typically associated with atorvastatin use.
Correct Answer is C
Explanation
Diabetes insipidus is a condition in which the kidneys are unable to conserve water, leading to excessive thirst and urination. It is treated with antidiuretic hormone (ADH), which helps the kidneys retain water and reduce urine output. When caring for a client with diabetes insipidus who is receiving ADH intranasally, it is important for the nurse to monitor the client’s serum osmolality.
Osmolality is a measure of the concentration of particles in a solution and can provide information about the client’s hydration status.
Monitoring serum osmolality can help determine if the ADH therapy is effective in managing the client’s diabetes insipidus.
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