A nurse is providing teaching for a client who received a prescription for an epinephrine autoinjector to treat anaphylaxis. Which of the following information should the nurse include in the teaching?

Use the autoinjector if shortness of breath is the only symptom of anaphylaxis.

Use the second autoinjector immediately after the first dose.

Hold the autoinjector firmly down for 10 seconds while injecting.

Inject into the buttock or deltoid.

Answer and Explanation

The Correct Answer is C

A. Use the autoinjector if shortness of breath is the only symptom of anaphylaxis: An epinephrine autoinjector should be used for any signs of anaphylaxis, not just shortness of breath. Symptoms such as hives, swelling, or difficulty breathing should all trigger its use.

B. Use the second autoinjector immediately after the first dose: The second dose of epinephrine is typically used if symptoms persist or recur after 5 to 15 minutes, not immediately after the first dose. The client should call emergency services after using the first dose and only use a second dose if directed by a healthcare provider.

C. Hold the autoinjector firmly down for 10 seconds while injecting: The correct procedure for using the epinephrine autoinjector is to hold it in place for 10 seconds to ensure the full dose is administered. This is an important step to ensure the medication is fully delivered.

D. Inject into the buttock or deltoid: The epinephrine autoinjector should be injected into the outer thigh (vastus lateralis muscle), not the buttock or deltoid. The thigh muscle allows for rapid absorption of the medication in an emergency.

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Correct Answer is B

Explanation

A. Hyponatremia: While hyponatremia can cause neurological symptoms, such as confusion and seizures, it is not typically associated with a positive Trousseau's sign. Trousseau's sign is more specifically related to calcium imbalances.
B. Hypocalcemia: A positive Trousseau's sign (a spasm of the hand and wrist when a blood pressure cuff is inflated) is a classic sign of hypocalcemia, which is low calcium levels in the blood. Numbness and tingling of the toes (paresthesia) are also common symptoms of hypocalcemia.
C. Hyperkalemia: Hyperkalemia typically causes muscle weakness, fatigue, and potential cardiac arrhythmias, but it does not directly cause a positive Trousseau's sign or numbness and tingling in the extremities.
D. Hypermagnesemia: Hypermagnesemia (high magnesium levels) typically causes symptoms such as muscle weakness, respiratory depression, and hypotension. It is not associated with a positive Trousseau's sign.

A. Distended jugular veins B. Low back pain C. Bounding pulses D. Hypertension

Correct Answer is B

Explanation

A. Distended jugular veins: Distended jugular veins are more indicative of fluid overload which is a potential complication of rapid blood transfusion or right-sided heart failure, not a hemolytic transfusion reaction.

B. Low back pain: Low back pain is a classic sign of a hemolytic transfusion reaction, which occurs when the immune system attacks the transfused red blood cells. This pain can be caused by the release of hemoglobin from lysed RBCs, which can accumulate in the kidneys and cause damage.

C. Bounding pulses: Bounding pulses are typically associated with fluid overload or hyperdynamic circulation and are not a specific sign of a hemolytic transfusion reaction.

D. Hypertension: Hypertension is not a specific or common sign of a hemolytic transfusion reaction. The reaction more typically involves fever, chills, pain, and changes in vital signs like tachycardia, rather than hypertension.

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A nurse is providing teaching for a client who received a prescription for an epinephrine autoinjector to treat anaphylaxis. Which of the following information should the nurse include in the teaching?

Nursing Test Bank

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