Question 1

A client is in the preoperative holding area prior to surgery.The nurse notes that the client has allergies to avocados and strawberries.What action by the nurse is best?&#10;A) Assess that the client has been NPO as directed.&#10;B) Communicate this information with dietary staff.&#10;C) Document the information in the client's chart.&#10;D) Ensure the information is relayed to the surgical team.

Accepted Answer

A client with allergies to avocados,strawberries,bananas,or nuts has a higher risk of latex allergy.The nurse should ensure that the surgical staff is aware of this so they can provide a latex-free environment.Ensuring the client's NPO status is important for a client having surgery but is not directly related to the risk of latex allergy.Dietary allergies will be communicated when a diet order is placed.Documentation should be thorough but does not take priority.

Question 2

A client with Sj&#246;gren's syndrome reports dry skin,eyes,mouth,and vagina.What nonpharmacologic comfort measure does the nurse suggest?&#10;A) Frequent eyedrops&#10;B) Home humidifier&#10;C) Strong moisturizer&#10;D) Tear duct plugs

Accepted Answer

A humidifier will help relieve many of the client's Sjögren's syndrome symptoms.Eyedrops and tear duct plugs only affect the eyes,and moisturizer will only help the skin.

Question 3

A nurse works in an allergy clinic.What task performed by the nurse takes priority?&#10;A) Checking emergency equipment each morning&#10;B) Ensuring informed consent is obtained as needed&#10;C) Providing educational materials in several languages&#10;D) Teaching clients how to manage their allergies

Accepted Answer

All actions are appropriate for this nurse; however,client safety is the priority.The nurse should ensure that emergency equipment is available and in good working order and that sufficient supplies of emergency medications are on hand as the priority responsibility.When it is appropriate for a client to give informed consent,the nurse ensures the signed forms are on the chart.Providing educational materials in several languages is consistent with holistic care.Teaching is always a major responsibility of all nurses.

Question 4

The nurse is caring for clients on the medical-surgical unit.What action by the nurse will help prevent a client from having a type II hypersensitivity reaction?&#10;A) Administering steroids for severe serum sickness&#10;B) Correctly identifying the client prior to a blood transfusion&#10;C) Keeping the client free of the offending agent&#10;D) Providing a latex-free environment for the client

Accepted Answer

A classic example of a type II hypersensitivity reaction is a blood transfusion reaction.These can be prevented by correctly identifying the client and cross-checking the unit of blood to be administered.Serum sickness is a type III reaction.Avoidance therapy is the cornerstone of treatment for a type IV hypersensitivity.Latex allergies are a type I hypersensitivity.

Question 5

A nurse has educated a client on an epinephrine auto-injector (EpiPen).What statement by the client indicates additional instruction is needed?&#10;A) &#34;I don't need to go to the hospital after using it.&#34;&#10;B) &#34;I must carry two EpiPens with me at all times.&#34;&#10;C) &#34;I will write the expiration date on my calendar.&#34;&#10;D) &#34;This can be injected right through my clothes.&#34;

Accepted Answer

Clients should be instructed to call 911 and go to the hospital for monitoring after using the EpiPen.The other statements show good understanding of this treatment.

Question 6

A client is receiving plasmapheresis as treatment for Goodpasture's syndrome.When planning care,the nurse places highest priority on interventions for which client problem?&#10;A) Reduced physical activity related to the disease's effects on the lungs&#10;B) Inadequate family coping related to the client's hospitalization&#10;C) Inadequate knowledge related to the plasmapheresis process&#10;D) Potential for infection related to the site for organism invasion

Accepted Answer

Physical diagnoses take priority over psychosocial diagnoses,so inadequate family coping and inadequate knowledge are not the priority.The client has a potential for infection because plasmapheresis is an invasive procedure.Reduced activity is manifested by changes in vital signs,oxygenation,or electrocardiogram,and/or reports of chest pain or shortness of breath.There is no information in the question to indicate that the client is experiencing reduced physical activity.

Question 7

The nursing student is studying hypersensitivity reactions.Which reactions are correctly matched with their hypersensitivity types? (Select all that apply.)&#10;A) Type I - Examples include hay fever and anaphylaxis&#10;B) Type II - Mediated by action of immunoglobulin M (IgM)&#10;C) Type III - Immune complex deposits in blood vessel walls&#10;D) Type IV - Examples are poison ivy and transplant rejection&#10;E) Type V - Examples include a positive tuberculosis test and sarcoidosis

Accepted Answer

Type I reactions are mediated by immunoglobulin E (IgE)and include hay fever,anaphylaxis,and allergic asthma.Type III reactions consist of immune complexes that form and deposit in the walls of blood vessels.Type IV reactions include responses to poison ivy exposure,positive tuberculosis tests,and graft rejection.Type II reactions are mediated by immunoglobulin G,not IgM.Type V reactions include Graves' disease and B-cell gammopathies.

Question 8

A client is in the hospital and receiving IV antibiotics.When the nurse answers the client's call light,the client presents an appearance as shown below:

What action by the nurse takes priority?

A) Administer epinephrine 1:1000, 0.3 mg IV push immediately.
B) Apply oxygen by facemask at 100% and a pulse oximeter.
C) Ensure a patent airway while calling the Rapid Response Team.
D) Reassure the client that these manifestations will go away.

Accepted Answer

The nurse should ensure the client's airway is patent and either call the Rapid Response Team or delegate this to someone else.Epinephrine needs to be administered right away,but not without a prescription by the physician unless standing orders exist.The client may need oxygen,but a patent airway comes first.Reassurance is important,but airway and calling the Rapid Response Team are the priorities.

Question 9

A client calls the clinic to report exposure to poison ivy and an itchy rash that is not helped with over-the-counter antihistamines.What response by the nurse is most appropriate?&#10;A) &#34;Antihistamines do not help poison ivy.&#34;&#10;B) &#34;There are different antihistamines to try.&#34;&#10;C) &#34;You should be seen in the clinic right away.&#34;&#10;D) &#34;You will need to take some IV steroids.&#34;

Accepted Answer

Since histamine is not the mediator of a type IV reaction such as with poison ivy,antihistamines will not provide relief.The nurse should educate the client about this.The client does not need to be seen right away.The client may or may not need steroids; they may be given either IV or orally.

Question 10

A client having severe allergy symptoms has received several doses of IV antihistamines.What action by the nurse is most important?&#10;A) Assess the client's bedside glucose reading.&#10;B) Instruct the client not to get up without help.&#10;C) Monitor the client frequently for tachycardia.&#10;D) Record the client's intake, output, and weight.

Accepted Answer

Antihistamines can cause drowsiness,so for the client's safety,he or she should be instructed to call for assistance prior to trying to get up.Hyperglycemia and tachycardia are side effects of sympathomimetics.Fluid and sodium retention are side effects of corticosteroids.

Question 11

A client suffered an episode of anaphylaxis and has been stabilized in the intensive care unit.When assessing the client's lungs,the nurse hears the following sounds.What medication does the nurse prepare to administer?
(Click the media button to hear the audio clip.)

A) Albuterol (Proventil) via nebulizer
B) Diphenhydramine (Benadryl) IM
C) Epinephrine 1:10,000 5 mg IV push
D) Methylprednisolone (Solu-Medrol) IV push

Accepted Answer

The answer of A client suffered an episode of anaphylaxis...

Question 12

A nurse suspects a client has serum sickness.What laboratory result would the nurse correlate with this condition? A) Blood urea nitrogen: 12 mg/dL B) Creatinine: 3.2 mg/dL C) Hemoglobin: 8.2 mg/dL D) White blood cell count: 12,000/mm³

Accepted Answer

The answer of A nurse suspects a client has serum...

Question 13

A client in the family practice clinic reports a 2-week history of an "allergy to something." The nurse obtains the following assessment and laboratory data:

About what medications and interventions does the nurse plan to teach this client? (Select all that apply.)

A) Elimination of any pets
B) Chlorpheniramine (Chlor-Trimaton)
C) Future allergy scratch testing
D) Proper use of decongestant nose sprays
E) Taking the full dose of antibiotics

Accepted Answer

The answer of A client in the family practice clinic...

Deck 20: Care of Patients with Immune Function Excess: Hypersensitivity (Allergy)and Autoimmunity