A nurse has educated a client on an epinephrine autoinjector. What statement by the client indicates additional instruction is needed?

I will write the expiration date on my calendar

I don’t need to go to the hospital after using it

This can be injected right through my clothes

I must carry two autoinjectors with me at all times

Answer and Explanation

The Correct Answer is B

Choice A reason: Marking the expiration date on a calendar is a proactive and correct safety measure. Epinephrine loses its potency over time, and a patient must ensure the medication is current to be effective during a life threatening anaphylactic event where every second is critical for survival.

Choice B reason: This statement is incorrect and indicates a need for further teaching. Epinephrine is a short acting medication that provides temporary relief from airway constriction and vasodilation. A biphasic reaction can occur, where symptoms return after the initial dose wears off, requiring immediate professional medical observation and stabilization.

Choice C reason: Epinephrine autoinjectors are designed for emergency use and can be effectively administered through most clothing, such as jeans or leggings. This design allows for rapid delivery of the medication without the delay of undressing, which is essential during a rapidly progressing allergic reaction.

Choice D reason: Patients are often prescribed a twin pack because a single dose may not be sufficient to reverse severe anaphylaxis, or a second dose may be needed if emergency services are delayed. Carrying two injectors ensures the patient has a backup for refractory symptoms or mechanical failure.

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Correct Answer is ["A","C","D","E"]

Explanation

Choice A reason: Full thickness burns involve the destruction of all skin layers and underlying structures, leading to a massive inflammatory response and "capillary leak" syndrome. This loss of intravascular fluid into the interstitial space causes a profound decrease in circulating volume, known as burn-induced hypovolemic shock.

Choice B reason: Hypertension is not an expected finding in the acute phase of a major burn injury. The primary hemodynamic challenge is hypotension due to fluid loss and systemic vasodilation. Hypertension would only be seen much later in the recovery phase or as a result of a pre-existing condition.

Choice C reason: Fluid volume deficit is a certainty in large percentage burns. The loss of the skin barrier leads to massive evaporative water loss, while the systemic inflammatory response causes fluid to shift from the vascular compartment into the tissues, resulting in severe dehydration and intravascular depletion.

Choice D reason: An increased pulse rate, or tachycardia, is a compensatory mechanism by the sympathetic nervous system. In response to a decreased stroke volume from fluid loss, the heart beats faster to attempt to maintain adequate cardiac output and perfusion to vital organs during the shock state.

Choice E reason: Decreased cardiac output occurs during the initial "eb b" phase of burn shock. The combination of reduced intravascular volume (low preload) and the release of myocardial depressant factors during the systemic inflammatory response leads to a significant reduction in the heart's overall pumping efficiency.

A. Pre-medicate the client for pain B. Remove the old dressing with non-sterile gloves C. Prepare the equipment and bandages at the bedside D. Place a sterile glove on the dominant hand

Correct Answer is A

Explanation

Choice A reason: Burn dressing changes are notoriously painful due to the exposure of raw tissue and mechanical debridement. Pre-medicating the client 20 to 30 minutes prior to the procedure ensures therapeutic drug levels are reached, facilitating client cooperation and preventing the physiological stress response associated with severe pain.

Choice B reason: Removing the old dressing is a necessary step, but it must occur after pain management has been addressed. If the nurse removes the dressing without prior medication, the client may experience excruciating pain, making it difficult to complete the sterile portion of the procedure safely.

Choice C reason: Preparing equipment at the bedside is a logistical requirement for any procedure. While important for efficiency, it does not take priority over the ethical and clinical necessity of ensuring the client is comfortable and physiologically prepared for a painful intervention.

Choice D reason: Placing a sterile glove is one of the final steps in the actual dressing application process. It occurs long after the initial assessment, pain management, and removal of the old dressing. Proper sequencing ensures that the sterile field remains uncontaminated throughout the procedure.

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A nurse has educated a client on an epinephrine autoinjector. What statement by the client indicates additional instruction is needed?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with full thickness burns on 40 percent of their body. What assessment findings does the nurse expect with this type of injury? (Select all that apply)

Correct Answer is ["A","C","D","E"]

Explanation

The nurse is preparing to perform a sterile dressing change on a client who obtained full-thickness burns on the right leg one week ago. Which intervention would the nurse implement first?

Correct Answer is A

Explanation

Which client is at the greatest risk of developing cardiogenic shock?

Which clinical manifestation indicates worsening in the condition of a client in the refractory phase of shock?

The nurse is caring for a client who is suffering from multiple organ dysfunction syndrome (MODS). What does the nursing plan of care focus on?

A nurse is caring for several clients at risk for shock. Which laboratory value is most important for the nurse to communicate with the primary health care provider?

A nurse cares for a client placed in skeletal traction. The client asks, “What is the main purpose of this type of traction?” How would the nurse respond?

The nurse is caring for a client with a broken femur. The client is at higher risk for which complication due to this specific bone fracture?

The nurse assesses a client who is admitted after a thermal burn injury to 60 percent of their body. Which action does the nurse take first?

A client diagnosed with Multiple Organ Dysfunction Syndrome (MODS) has been started on vasopressin. What assessment finding requires the nurse to communicate with the primary health care provider immediately?