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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Nitrofurantoin is an antibiotic commonly used to treat urinary tract infections. One of the adverse eﬀects of nitrofurantoin is diarrhea, which may be severe and watery. Therefore, it is important for the home care nurse to inform the client that the diarrhea may be a side eﬀect of the medication and requires further evaluation. The nurse should instruct the client to stop taking the medication and contact their healthcare provider for further assessment and treatment. The nurse should also assess the client's ﬂuid and electrolyte status and monitor for signs of dehydration.

Option a is important to consider, but it does not address the potential adverse eﬀect of the medication.

Option c may be appropriate in some cases, but it is not the priority intervention at this time.

Option d is not necessarily true and may cause unnecessary alarm to the client.

A. Assess urine output. B. Perform a bladder scan. C. Monitor blood pressure. D. Obtain daily weights.

Correct Answer is C

Explanation

Tamsulosin is an alpha-1 adrenergic receptor blocker that is commonly used to treat benign prostatic hyperplasia (BPH). One of the potential adverse reactions of tamsulosin is hypotension, which can be manifested as dizziness, lightheadedness, and fainting. Therefore, monitoring blood pressure is a crucial intervention for clients receiving tamsulosin.

Assessing urine output (option a) and performing a bladder scan (option b) may be appropriate interventions for clients with urinary retention or other urinary tract issues, but they are not specific to monitoring adverse reactions to tamsulosin.

Obtaining daily weights (option d) may be useful for monitoring ﬂuid balance in some clients, but it is not directly related to adverse reactions to tamsulosin.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Two months after taking nitrofurantoin for a bacterial infection, a client reports the onset of severe, watery diarrhea to the home care nurse. How should the nurse respond?

Correct Answer is B

Explanation

A client with benign prostatic receives a new prescription of tamsulosin. Which intervention should the nurse use to monitor an adverse reaction?

Correct Answer is C

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?