The nurse is caring for a patient with wheezes, shortness of breath, urticaria and itching after receiving a new antibiotic The nurse understands that the epinephrine in this situation would be administered intramuscularly (IM), rather than intravenously (IV) because:

IM epinephrine is the fastest route of administration

IV epinephrine is only administered during cardiac arrest

Epinephrine would not be administered in this situation

IM epinephrine is less concentrated than IV.

Answer and Explanation

The Correct Answer is B

A) IM epinephrine is the fastest route of administration:
While epinephrine is often administered intramuscularly in cases of anaphylaxis and allergic reactions, the speed of action is not the primary reason for choosing this route over intravenous (IV) administration in this situation. Intramuscular administration of epinephrine allows for a rapid onset of action, but it is not necessarily the fastest route compared to IV. IV administration would act more quickly in an emergency setting where immediate blood circulation is critical, but IM is preferred in allergic reactions to prevent excessive systemic effects and to avoid rapid peaks in plasma levels.

B) IV epinephrine is only administered during cardiac arrest:
Epinephrine is generally administered intravenously during life-threatening situations such as cardiac arrest or severe shock, where immediate circulatory effects are needed. In cases of anaphylaxis, however, intramuscular (IM) administration of epinephrine is the preferred route because it allows for a more controlled absorption rate and reduces the risk of excessive blood pressure and other adverse cardiovascular effects. This is the correct rationale for why epinephrine is administered IM in the context of an allergic reaction.

C) Epinephrine would not be administered in this situation:
Epinephrine is the first-line treatment for severe allergic reactions and anaphylaxis, especially in cases where symptoms like wheezing, shortness of breath, urticaria, and itching are present. Therefore, withholding epinephrine is not an appropriate response in this situation. Immediate intervention with epinephrine is critical to reverse the symptoms of anaphylaxis and prevent further respiratory distress or cardiovascular collapse.

D) IM epinephrine is less concentrated than IV:
The concentration of epinephrine used for IM and IV administration is the same. The primary reason for choosing the IM route over the IV route is the slower absorption and the fact that it minimizes the risk of a rapid increase in systemic blood pressure and other adverse reactions. While IM epinephrine may be absorbed more slowly than IV, its concentration is appropriate for treating anaphylaxis effectively. The choice of IM is based on safety and controlled response, not on the concentration of the drug.

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Correct Answer is C

Explanation

A) Blood pressure 102/78:
This blood pressure is within an acceptable range, especially after resuscitation with fluids and blood products. While hypotension is a concern in hypovolemic shock, this blood pressure is stable and does not indicate an immediate need for intervention. Blood pressure monitoring is essential, but this finding is not as urgent as other options.

B) Pulse oximetry 95%:
A pulse oximetry reading of 95% is generally considered within normal limits for a patient who has undergone resuscitation and is stable. Oxygen saturation levels should be monitored, but this finding does not indicate an immediate need for intervention. Values below 90% would be more concerning, especially in trauma patients, but 95% is acceptable.

C) Crackles at bilateral bases:
The presence of crackles at the bilateral lung bases is a sign of pulmonary edema, which can occur as a result of fluid overload, especially after aggressive resuscitation with fluids like lactated Ringer's solution (LR) and blood products. In hypovolemic shock, rapid infusion of fluids can overwhelm the heart's ability to handle the volume, leading to fluid accumulation in the lungs. This finding is concerning because it can indicate a shift from hypovolemic shock to a state of volume overload, which can worsen respiratory function and lead to acute respiratory distress syndrome (ARDS).

D) Heart rate 105 beats per minute:
A heart rate of 105 beats per minute is slightly elevated but can be expected in a patient who has experienced trauma and is undergoing fluid resuscitation. Tachycardia is often seen in hypovolemic shock as the body compensates for decreased circulating volume. While monitoring the heart rate is important, this finding does not indicate an immediate life-threatening concern compared to crackles in the lungs, which suggest pulmonary edema.

A. Provide honest answers to the cliche's questions B. Avoid eve contact with the client during care C. A Provide limited explanations of procedures needed for' D. Avoid giving the client choices regarding their care

Correct Answer is A

Explanation

A) Provide honest answers to the client’s questions:
Providing honest answers to the client's questions is essential in promoting comfort, especially when they have a new diagnosis of bladder cancer. Patients often experience anxiety and uncertainty when facing a new diagnosis, so being open and transparent with information can help alleviate fears and build trust.

B) Avoid eye contact with the client during care:
Avoiding eye contact with the client can contribute to feelings of isolation and discomfort. Eye contact is an important form of non-verbal communication that can help establish a rapport and show empathy. Avoiding eye contact could make the client feel rejected or neglected, which would increase their anxiety and distress.

C) Provide limited explanations of procedures needed for care:
Providing limited explanations of procedures may leave the client feeling more confused or fearful about what is happening. While it's important to avoid overwhelming the patient with too much information, clear and concise explanations about procedures and treatments are essential to reduce anxiety and help the patient feel more in control of the situation.

D) Avoid giving the client choices regarding their care:
Avoiding giving the patient choices can make them feel powerless, which can increase feelings of anxiety and frustration. Offering choices when appropriate allows the patient to feel more in control of their care, which can reduce stress and enhance their sense of autonomy.

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The nurse is caring for a patient with wheezes, shortness of breath, urticaria and itching after receiving a new antibiotic The nurse understands that the epinephrine in this situation would be administered intramuscularly (IM), rather than intravenously (IV) because:

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is caring for a client who has a new diagnosis of bladder cancer Which of the following interventions should the nurse take to promote comfort?

Correct Answer is A

Explanation

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