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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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Gently squeeze the tubing to remove excess drainage: Squeezing the tubing is not recommended as it could cause injury or increase pressure within the system. The nurse should not manipulate the tubing in this way, as it does not address the continuous bubbling.
B. Raise the drainage system to the client's chest level: The drainage system should always be below the level of the client's chest to promote proper drainage. Raising the system to chest level could disrupt the drainage process and cause complications.
C. Clamp the tubing to check for air leaks: Continuous bubbling in the water seal chamber may indicate an air leak in the system. The nurse should clamp the tubing temporarily to isolate the source of the leak and check for any external leaks or loose connections.
D. Empty the collection chamber: The collection chamber should only be emptied when it is full. Continuous bubbling in the water seal chamber is more likely an indication of an air leak. The nurse should first assess for leaks before considering emptying the chamber.

A. Excessive intake of bicarbonate B. Acute respiratory distress syndrome C. Hyperventilation D. Kyphosis

Correct Answer is C

Explanation

A. Excessive intake of bicarbonate: Excessive intake of bicarbonate would more lead to metabolic alkalosis, not respiratory alkalosis. Respiratory alkalosis is caused by excessive exhalation of carbon dioxide, not by intake of bicarbonate.

B. Acute respiratory distress syndrome (ARDS): ARDS generally leads to respiratory acidosis due to impaired gas exchange and retention of carbon dioxide, not respiratory alkalosis.

C. Hyperventilation: Hyperventilation is the most common cause of respiratory alkalosis. It leads to excessive exhalation of carbon dioxide, causing a decrease in blood carbon dioxide levels and an increase in blood pH.

D. Kyphosis: Kyphosis, a spinal deformity, could affect lung expansion but is not a direct cause of respiratory alkalosis. It might lead to other respiratory issues, but it does not primarily increase the risk of alkalosis.

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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?

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