Question 1

The nurse is caring for a patient with serum sickness. Which intervention should the nurse implement?

Accepted Answer

Serum sickness is a reaction similar to an allergy. The primary symptoms include fever, joint pain, rash, and swelling. Acetaminophen (Tylenol) can be used to manage fever and pain associated with serum sickness. The other options are not standard interventions for treating serum sickness.

Question 2

A patient is receiving a transfusion of packed RBCs. Ten minutes after the infusion begins, the patient reports low back pain and a headache. Which action should the nurse take first?

Accepted Answer

Stopping the blood infusion is the first and most critical action to take in response to signs of a possible transfusion reaction, such as low back pain and a headache.

Question 3

The nurse is teaching a patient with SLE about avoiding triggers. Which statement made by the patient indicates a need for further teaching?

Accepted Answer

Exposure to sunlight can exacerbate symptoms of Systemic Lupus Erythematosus (SLE), as many patients with SLE are photosensitive. Avoiding sunlight or using protective measures is generally recommended.

Question 4

The nurse is caring for a patient who is stung by a wasp. Which manifestation should the nurse expect if an allergic reaction develops?

Accepted Answer

Hives (urticaria) are a common manifestation of an allergic reaction, including reactions to insect stings such as wasp stings.

Question 5

A patient is to receive a transfusion of packed RBCs. Before administering the transfusion, which action should the nurse take?

Accepted Answer

Verifying the blood type of both the patient and the donor is crucial to prevent transfusion reactions, which can be life-threatening.

Question 6

The nurse is contributing to the teaching plan for a patient who is allergic to dust. Which environmental modification should the nurse recommend be included in the teaching plan to help control symptoms?

Accepted Answer

Covering heating ducts with filters can help reduce the amount of dust circulating in the air, which is beneficial for someone who is allergic to dust. This can help control symptoms by minimizing exposure to allergens.

Question 7

The nurse is reviewing orders for a patient with systemic lupus erythematosus (SLE). For which medication should the nurse request clarification?

Accepted Answer

Phenytoin (Dilantin) is an anticonvulsant that can exacerbate symptoms of SLE or cause drug-induced lupus, so its use should be clarified.

Question 8

The nurse is teaching a patient about allergic rhinitis. Which statement indicates a need for further teaching?

Accepted Answer

The answer of The nurse is teaching a patient about...

Question 9

The nurse is caring for a group of patients. Which patient should the nurse see first?

Accepted Answer

The patient receiving a blood transfusion who reports chills and low back pain should be seen first as these symptoms could indicate a transfusion reaction, which is a medical emergency.

Question 10

A patient is stabilized after having an allergic reaction. Which preventive instructions should the nurse reinforce with the patient?

Accepted Answer

Wearing medical alert identification is crucial for patients with a history of allergic reactions, as it provides critical information to healthcare providers in case of an emergency.

Question 11

A patient with type O blood is scheduled to undergo open heart surgery. Which blood type would this patient receive?

Accepted Answer

A patient with type O blood can only receive type O blood because it does not contain A or B antigens, making it the universal donor type. Other blood types (A, B, AB) contain antigens that would be recognized as foreign by the immune system of a person with type O blood, leading to a potentially dangerous transfusion reaction.

Question 12

The nurse is caring for a patient with SLE. The nurse notes that the patient has foamy, "coke"-colored urine. Which action should the nurse take?

Accepted Answer

Foamy, "coke"-colored urine can indicate kidney involvement, such as nephritis, which is a common complication of systemic lupus erythematosus (SLE). It is important to notify the healthcare provider for further assessment and management.

Question 13

The nurse is contributing to a group of patients care plans. Which patient should the nurse identify as being at risk for developing serum sickness?

Accepted Answer

Serum sickness is a reaction that can occur in response to certain medications, including antibiotics like penicillin. It is an immune system reaction to proteins in the drug, which the body may recognize as foreign.

Question 14

The nurse is caring for a patient who underwent a liver transplant and is taking cyclosporine (Sandimmune) and azathioprine (Imuran). Which important information should the nurse teach the patient regarding the medication?

Accepted Answer

Cyclosporine and azathioprine suppress the immune system to prevent organ rejection, increasing the risk of infection. Patients should be instructed to report any signs of infection immediately for prompt treatment.

Question 15

The nurse is teaching a patient about atopic dermatitis (Eczema). Which statement made by the patient indicates an understanding of the teaching?

Accepted Answer

Soaking in a lukewarm bath can help soothe the skin and provide relief from the itching associated with atopic dermatitis. It's a recommended practice to help maintain skin hydration, which is crucial for managing eczema symptoms.

Question 16

The nurse is caring for a patient with pernicious anemia. Which deficiency is this patient experiencing?

Accepted Answer

Pernicious anemia is caused by a deficiency of vitamin B12, which is necessary for the production of red blood cells.

Question 17

The nurse is preparing to administer levofloxacin (Levaquin) to a patient with pneumonia. Which is most important for the nurse to ask prior to administering the medication?

Accepted Answer

Levofloxacin (Levaquin) is an antibiotic, and it is crucial to ask about medication allergies to avoid administering a drug that the patient may be allergic to, which could lead to a severe allergic reaction.

Question 18

The nurse contributed to the teaching plan for a patient with a history of allergies to pollen. Which patient action indicates an understanding of how to control this disease?

Accepted Answer

Wearing a mask when mowing the lawn helps to reduce the inhalation of pollen, which is a common trigger for allergic reactions in individuals sensitive to pollen. This action indicates an understanding of how to minimize exposure to allergens.

Question 19

The nurse is caring for a patient with angioedema. Which nursing action should have the highest priority?

Accepted Answer

Monitoring for restlessness is crucial as it can indicate airway obstruction, a life-threatening complication of angioedema.

Question 20

The nurse is caring for a patient with idiopathic autoimmune hemolytic anemia. Which action should the nurse include in the plan of care for this patient?

Accepted Answer

The answer of The nurse is caring for a patient...

Quiz 19: Nursing Care of Patients With Immune Disorders