Hypersensitivity
N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 19. The nurse enters a clients room and observes the manifestations shown below. What action should the nurse take first? a. Prepare to administer diphenhydramine (Benadryl). b. Prepare to administer epinephrine. c. Assess the clients respiratory status. d. Get a full set of vital signs.
C This client has angioedema, and the priority action is to assess her respiratory status because respiratory collapse may follow. The nurse should have someone else notify the Rapid Response Team and prepare to administer epinephrine. DIF: Cognitive Level: Application/Applying or higher
208 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 3. A patient is being evaluated for possible atopic dermatitis. The nurse expects elevation of which laboratory value? a. IgE b. IgA c. Basophils d. Neutrophils
A Serum IgE is elevated in an allergic response (type 1 hypersensitivity disorders). The eosinophil level will be elevated rather than neutrophil or basophil counts. IgA is located in body secretions and would not be tested when evaluating a patient who has symptoms of atopic dermatitis. DIF: Cognitive Level: Apply (application)
N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Evaluation) 13. A client is hospitalized with Goodpastures syndrome. Which intervention by the nurse takes priority? a. Monitor urine output and renal function tests. b. Teach the client to manage peritoneal dialysis. c. Administer antibiotics strictly on time. d. Have separate IV access for immune globulin (IVIG) administration.
A The main cause of death in clients with Goodpastures syndrome is renal failure. The nurse must monitor renal function meticulously. Some, but not all, clients need dialysis and IVIG infusions. Antibiotics are not used in the management of this condition. DIF: Cognitive Level: Application/Applying or higher
215 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 6. Which teaching should the nurse provide about intradermal skin testing to a patient with possible allergies? a. Do not eat anything for about 6 hours before the testing. b. Take an oral antihistamine about an hour before the testing. c. Plan to wait in the clinic for 20 to 30 minutes after the testing. d. Reaction to the testing will take about 48 to 72 hours to occur.
C Allergic reactions usually occur within minutes after injection of an allergen, and the patient will be monitored for at least 20 minutes for anaphylactic reactions after the testing. Medications that might modify the response, such as antihistamines, should be avoided before allergy testing. There is no reason to be NPO for skin testing. Results with intradermal testing occur within minutes. DIF: Cognitive Level: Apply (application)
214 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 21. Immediately after the nurse administers an intracutaneous injection of an allergen on the forearm, a patient complains of itching at the site and of weakness and dizziness. What action should the nurse take first? a. Remind the patient to remain calm. b. Administer subcutaneous epinephrine. c. Apply a tourniquet above the injection site. d. Rub a local antiinflammatory cream on the site.
C Application of a tourniquet will decrease systemic circulation of the allergen and should be the first reaction. A local antiinflammatory cream may be applied to the site of a cutaneous test if the itching persists. Epinephrine will be needed if the allergic reaction progresses to anaphylaxis. The nurse should assist the patient to remain calm, but this is not an adequate initial nursing action. DIF: Cognitive Level: Apply (application)
N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Interactions/Side Effects) MSC: Integrated Process: Nursing Process (Implementation) 5. Which condition is a type II hypersensitivity reaction? a. Allergic rhinitis b. Positive purified protein derivative (PPD) test for tuberculosis c. Transfusion reaction to improper blood type d. Serum sickness after receiving immune globulin
C Common clinical situations caused by type II hypersensitivities include hemolytic transfusion reactions. Type II hypersensitivity reactions are caused by antibodies directed against body tissues that have some form of non-self (foreign) protein attached to them. Allergic rhinitis is an example of a type I hypersensitivity. A positive PPD test is an example of a type IV reaction. Serum sickness is a type III reaction. DIF: Cognitive Level: Knowledge/Remembering
223 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 17. A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse prepare for this patient? a. Administration of immunosuppressant medications b. Insertion of an arteriovenous graft for hemodialysis c. Placement of the patient on the transplant waiting list d. A blood draw for human leukocyte antigen (HLA) matching
A Acute rejection is treated with the administration of additional immunosuppressant drugs such as corticosteroids. Because acute rejection is potentially reversible, there is no indication that the patient will require another transplant or hemodialysis. There is no indication for repeat HLA testing. DIF: Cognitive Level: Apply (application)
p. 383 TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 2. What intervention does the nurse implement to provide for client safety during intradermal allergy testing? a. Stay with the client and ensure that emergency equipment is in the room. b. Pretreat the skin area to be tested with a cortisone-based cream. c. Apply oxygen by mask or nasal cannula before injecting the test agent. d. Cover the examination table and pillow with plastic or an ultrafine mesh.
A Although it is usually a safe procedure, intradermal testing increases the risk for an adverse reaction, including anaphylaxis. Emergency equipment should be available. Pretreating the skin with cortisone will not decrease the risk of anaphylaxis. Applying oxygen will not help prevent a reaction. Covering the examination table will also not prevent allergic reactions. DIF: Cognitive Level: Application/Applying or higher
204 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 15. The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions? a. After a couple of years, it is likely that I will be able to stop taking the cyclosporine. b. If I develop an acute rejection episode, I will need to have other types of drugs given IV. c. I need to be monitored closely because I have a greater chance of developing malignant tumors. d. The drugs are given in combination because they inhibit different ways the kidney can be rejected.
A Cyclosporine, a calcineurin inhibitor, will need to be continued for life. The other patient statements are accurate and indicate that no further teaching is necessary about those topics. DIF: Cognitive Level: Apply (application)
N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesDosage Calculation) MSC: Integrated Process: Nursing Process (Implementation) 9. Which intervention is most important for the nurse to teach the client who is recovering from an allergic reaction to a bee sting? a. How to use an EpiPen b. Wearing a medical alert bracelet c. Avoiding contact with the allergen d. Keeping diphenhydramine (Benadryl) available
A If an anaphylactic reaction starts, the client will need to self-medicate very rapidly with the EpiPen. He or she should carry it at all times and should be proficient in its assembly and use. This is the highest priority intervention. The client should get a medical alert bracelet and keep away from bees if at all possible. It is also advised that diphenhydramine be kept on hand in case of a less severe reaction. DIF: Cognitive Level: Application/Applying or higher
N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlAccident/Injury Prevention) MSC: Integrated Process: Nursing Process (Implementation) 18. A nurse suspects that a client has serum sickness. For which manifestation does the nurse assess the client? a. Joint pain b. Allergic rhinitis c. Stridor d. Wheezing
A Serum sickness is a delayed reaction, type III. Signs and symptoms include fever, arthralgia, fever, rash, malaise, and lymphadenopathy. The other signs and symptoms are related to type I allergic reactions. DIF: Cognitive Level: Application/Applying or higher
221 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 19. A patient who has received allergen testing using the cutaneous scratch method has developed itching and swelling at the skin site. Which action should the nurse take first? a. Administer epinephrine. b. Apply topical hydrocortisone. c. Monitor the patient for lower extremity edema. d. Ask the patient about exposure to any new lotions or soaps.
A The initial symptoms of anaphylaxis are itching and edema at the site of the exposure. Hypotension, tachycardia, dilated pupils, and wheezes occur later. Rapid administration of epinephrine when excessive itching or swelling at the skin site is observed can prevent the progression to anaphylaxis. Topical hydrocortisone would not deter an anaphylactic reaction. Exposure to lotions and soaps does not address the immediate concern of a possible anaphylactic reaction. The nurse should not wait and observe for edema. The nurse should act immediately in order to prevent progression to anaphylaxis. DIF: Cognitive Level: Apply (application)
216 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment 13. Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What would the nurse suspect is the cause of this patients skin rash? a. The donor T cells are attacking the patients skin cells. b. The patients antibodies are rejecting the donor bone marrow. c. The patient is experiencing a delayed hypersensitivity reaction. d. The patient will need treatment to prevent hyperacute rejection.
A The patients history and symptoms indicate that the patient is experiencing graft-versus-host disease, in which the donated T cells attack the patients tissues. The history and symptoms are not consistent with rejection or delayed hypersensitivity. DIF: Cognitive Level: Understand (comprehension)
357 KEY: Autoimmune disorder| infection| nursing diagnosis MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 8. A nurse has educated a client on an epinephrine auto-injector (EpiPen). What statement by the client indicates additional instruction is needed? a. I dont need to go to the hospital after using it. b. I must carry two EpiPens with me at all times. c. I will write the expiration date on my calendar. d. This can be injected right through my clothes.
A 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. DIF: Evaluating/Synthesis
355 KEY: Hypersensitivities| immunity| antibodies MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 5. 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? a. Antihistamines do not help poison ivy. b. There are different antihistamines to try. c. You should be seen in the clinic right away. d. You will need to take some IV steroids.
A 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. DIF: Understanding/Comprehension
353 KEY: Rapid Response Team| critical rescue| anaphylaxis| resuscitation| epinephrine MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 11. A client suffered an episode of anaphylaxis and has been stabilized in the intensive care unit. When assessing the clients 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
A The nurse has auscultated wheezing in the clients lungs and prepares to administer albuterol, which is a bronchodilator, or assists respiratory therapy with administration. Diphenhydramine is an antihistamine. Epinephrine is given during an acute crisis in a concentration of 1:1000. Methylprednisolone is a corticosteroid. DIF: Analyzing/Analysis
N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlAccident/Injury Prevention) MSC: Integrated Process: Nursing Process (Assessment) 2. The nurse is preparing to administer a medication when the client states, Im allergic to that. How will the nurse proceed? (Select all that apply.) a. Check the chart for allergies. b. Notify the health care provider. c. Ask what reaction the client gets. d. Continue to give the medication. e. Perform a skin test first. f. Notify the pharmacist. g. Document the allergy on the chart.
A, B, C, F, G If a client states that he or she has an allergy to a medication, the nurse should not administer the medication. The nurse should find out what reaction the client experiences from the medication and then should notify the health care provider and the pharmacist of the clients response. The nurse should document the allergy on the chart, including the reaction to the medication and notification of the provider and the pharmacist, and should indicate what other drug was ordered in its place. Before administering any drug, the nurse should have already checked the chart for allergies. DIF: Cognitive Level: Application/Applying or higher
354 KEY: Anaphylaxis| bronchodilator| nursing assessment| medication administration| respiratory system| respiratory assessment MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies MULTIPLE RESPONSE 1. The nursing student is studying hypersensitivity reactions. Which reactions are correctly matched with their hypersensitivity types? (Select all that apply.) a. Type I Examples include hay fever and anaphylaxis b. Type II Mediated by action of immunoglobulin M (IgM) c. Type III Immune complex deposits in blood vessel walls d. Type IV Examples are poison ivy and transplant rejection e. Type V Examples include a positive tuberculosis test and sarcoidosis
A, C, D 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. DIF: Remembering/Knowledge
214 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity OTHER 1. A patient who is receiving an IV antibiotic develops wheezes and dyspnea. In which order should the nurse implement these prescribed actions? (Put a comma and a space between each answer choice [A, B, C, D, E]). a. Discontinue the antibiotic infusion. b. Give diphenhydramine (Benadryl) IV. c. Inject epinephrine (Adrenalin) IM or IV. d. Prepare an infusion of dopamine (Intropin). e. Start 100% oxygen using a nonrebreather mask.
A, E, C, B, D The nurse should initially discontinue the antibiotic because it is the likely cause of the allergic reaction. Next, oxygen delivery should be maximized, followed by treatment of bronchoconstriction with epinephrine administered IM or IV. Diphenhydramine will work more slowly than epinephrine, but will help prevent progression of the reaction. Because the patient currently does not have evidence of hypotension, the dopamine infusion can be prepared last. DIF: Cognitive Level: Apply (application)
211 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 24. A nurse has obtained donor tissue typing information about a patient who is waiting for a kidney transplant. Which results should be reported to the transplant surgeon? a. Patient is Rh positive and donor is Rh negative b. Six antigen matches are present in HLA typing c. Results of patient-donor cross matching are positive d. Panel of reactive antibodies (PRA) percentage is low
C Positive crossmatching is an absolute contraindication to kidney transplantation, since a hyperacute rejection will occur after the transplant. The other information indicates that the tissue match between the patient and potential donor is acceptable. DIF: Cognitive Level: Apply (application)
N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 12. A client states that he is allergic to poison ivy. Which statement by the client indicates a good understanding of this type of sensitivity? a. Drinking 3 liters of water a day will prevent kidney damage. b. I will always wear a medical alert bracelet for this allergy. c. I need to try to avoid coming into contact with poison ivy. d. I should carry diphenhydramine (Benadryl) with me at all times.
C Reactions to poison ivy are a type IV hypersensitivity reaction. They are cell mediated by T-lymphocytes in the skin. Avoidance of the offending allergen is the most appropriate intervention. The complexes do not form or precipitate in the kidney. This type of hypersensitivity does not represent an immediate life-threatening emergency and does not respond to histamine antagonists (diphenhydramine). DIF: Cognitive Level: Application/Applying or higher
219 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 12. Which patient should the nurse assess first? a. Patient with urticaria after receiving an IV antibiotic b. Patient who has graft-versus-host disease and severe diarrhea c. Patient who is sneezing after having subcutaneous immunotherapy d. Patient with multiple chemical sensitivities who has muscle stiffness
C Sneezing after subcutaneous immunotherapy may indicate impending anaphylaxis and assessment and emergency measures should be initiated. The other patients also have findings that need assessment and intervention by the nurse, but do not have evidence of life-threatening complications. DIF: Cognitive Level: Analyze (analysis)
p. 392 TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 16. A nurse is planning care for a client with Sjgrens syndrome. At what point does the nurse determine that priority outcomes have been met? a. The client states that he or she is not as fatigued as previously. b. The client dresses attractively despite gaining a large amount of weight. c. The oral mucosa is intact and no systemic signs of infection are present. d. The client is able to complete activities of daily living with minimal shortness of breath.
C The major symptoms associated with Sjgrens syndrome include dry eyes caused by insufficient tear production and dry mucous membranes of the nose, mouth, and vaginal tissues. Increased dryness reduces the tissues natural defenses against infection. If the client shows no signs of infection, priority outcomes have been met. The other observations do not meet a priority outcome. DIF: Cognitive Level: Application/Applying or higher
354 KEY: Allergic response| antihistamines| patient safety| falls MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 10. A client is in the hospital and receiving IV antibiotics. When the nurse answers the clients 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.
C The nurse should ensure the clients 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. DIF: Analyzing/Analysis
211 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 4. An older adult patient who is having an annual check-up tells the nurse, I feel fine, and I dont want to pay for all these unnecessary cancer screening tests! Which information should the nurse plan to teach this patient? a. Consequences of aging on cell-mediated immunity b. Decrease in antibody production associated with aging c. Impact of poor nutrition on immune function in older people d. Incidence of cancer-stimulating infections in older individuals
A The primary impact of aging on immune function is on T cells, which are important for immune surveillance and tumor immunity. Antibody function is not affected as much by aging. Poor nutrition can also contribute to decreased immunity, but there is no evidence that it is a contributing factor for this patient. Although some types of cancer are associated with specific infections, this patient does not have an active infection. DIF: Cognitive Level: Apply (application)
1. A nurse works in an allergy clinic. What task performed by the nurse takes priority? a. Checking emergency equipment each morning b. Ensuring informed consent is obtained as needed c. Providing educational materials in several languages d. Teaching clients how to manage their allergies
A 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. DIF: Applying/Application
218 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 11. Which statement by a patient would alert the nurse to a possible immunodeficiency disorder? a. I take one baby aspirin every day to prevent stroke. b. I usually eat eggs or meat for at least 2 meals a day. c. I had my spleen removed many years ago after a car accident. d. I had a chest x-ray 6 months ago when I had walking pneumonia.
C Splenectomy increases the risk for septicemia from bacterial infections. The patients protein intake is good and should improve immune function. Daily aspirin use does not affect immune function. A chest x-ray does not have enough radiation to suppress immune function. DIF: Cognitive Level: Apply (application)
215-216 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 8. While obtaining a health history from a patient, the nurse learns that the patient has a history of allergic rhinitis and multiple food allergies. Which action by the nurse is most appropriate? a. Encourage the patient to carry an epinephrine kit in case a type IV allergic reaction to latex develops. b. Advise the patient to use oil-based hand creams to decrease contact with natural proteins in latex gloves. c. Document the patients allergy history and be alert for any clinical manifestations of a type I latex allergy. d. Recommend that the patient use vinyl gloves instead of latex gloves in preventing blood-borne pathogen contact.
C The patients allergy history and occupation indicate a risk of developing a latex allergy. The nurse should be prepared to manage any symptoms that may occur. Epinephrine is not an appropriate treatment for contact dermatitis that is caused by a type IV allergic reaction to latex. Oil-based creams will increase the exposure to latex from latex gloves. Vinyl gloves are appropriate to use when exposure to body fluids is unlikely. DIF: Cognitive Level: Apply (application)
221 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 18. The charge nurse is assigning rooms for new admissions. Which patient would be the most appropriate roommate for a patient who has acute rejection of an organ transplant? a. A patient who has viral pneumonia b. A patient with second-degree burns c. A patient who is recovering from an anaphylactic reaction to a bee sting d. A patient with graft-versus-host disease after a recent bone marrow transplant
C Treatment for a patient with acute rejection includes administration of additional immunosuppressants, and the patient should not be exposed to increased risk for infection as would occur from patients with viral pneumonia, graft-versus-host disease, and burns. There is no increased exposure to infection from a patient who had an anaphylactic reaction. DIF: Cognitive Level: Apply (application)
N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialLaboratory Values) MSC: Integrated Process: Nursing Process (Assessment) 15. How does the type V hypersensitivity reaction differ from other reactions? a. It is cell mediated rather than antibody mediated. b. It is an immediate response rather than a delayed response. c. It produces a stimulatory response to normal tissues. d. It results in more severe tissue damage than is caused by other types of reactions.
C Type V hypersensitivity reactions are known as stimulatory responses. The classic example of type V hypersensitivity is Graves disease, in which the person makes a large amount of antibody that binds to the thyroid-stimulating hormone receptor antibody (TSHr-Ab) on thyroid tissue. The binding of this antibody to the TSH receptor activates the receptor, greatly stimulating the thyroid gland and causing severe hyperthyroid symptoms. This type of reaction is not cell mediated. It is not an immediate response, nor does it cause more severe tissue damage. DIF: Cognitive Level: Comprehension/Understanding
214 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 22. A clinic patient is experiencing an allergic reaction to an unknown allergen. Which action is most appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Perform a focused physical assessment. b. Obtain the health history from the patient. c. Teach the patient about the various diagnostic studies. d. Administer skin testing by the cutaneous scratch method.
D LPN/LVNs are educated and licensed to administer medications under the supervision of an RN. RN-level education and the scope of practice include assessment of health history, focused physical assessment, and patient teaching. DIF: Cognitive Level: Apply (application)
218 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 10. The nurse is caring for a patient undergoing plasmapheresis. The nurse should assess the patient for which clinical manifestation? a. Shortness of breath b. High blood pressure c. Transfusion reaction d. Numbness and tingling
D Numbness and tingling may occur as the result of the hypocalcemia caused by the citrate used to prevent coagulation. The other clinical manifestations are not associated with plasmapheresis. DIF: Cognitive Level: Apply (application)
350 KEY: Immune disorders| inflammation| resuscitation| anaphylaxis| medical emergencies| patient safety MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 2. 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? a. Assess that the client has been NPO as directed. b. Communicate this information with dietary staff. c. Document the information in the clients chart. d. Ensure the information is relayed to the surgical team.
D 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 clients 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. DIF: Applying/Application
357 KEY: Autoimmune disorders| skin| patient education| nonpharmacologic comfort interventions MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort 7. A client is receiving plasmapheresis as treatment for Goodpastures syndrome. When planning care, the nurse places highest priority on interventions for which client problem? a. Reduced physical activity related to the diseases effects on the lungs b. Inadequate family coping related to the clients hospitalization c. Inadequate knowledge related to the plasmapheresis process d. Potential for infection related to the site for organism invasion
D 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. DIF: Applying/Application
p. 391 TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 8. What dose of epinephrine does the nurse prepare for a client in anaphylaxis who is 6 feet 3 inches tall and weighs 250 lb? a. 0.2 mL of a 1:1000 solution b. 0.5 mL of a 1:1000 solution c. 0.3 mL of a 1:10,000 solution d. 0.5 mL of a 1:10,000 solution
B Adult doses of epinephrine for anaphylaxis range between 0.3 and 0.5 mL of a 1:1000 solution. Because this client is large, the nurse should be prepared to give the higher dose initially. DIF: Cognitive Level: Application/Applying or higher
N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Assessment) 14. A client is in the clinic having had rhinorrhea and headache for the last 2 weeks. Which laboratory value alerts the nurse to the possibility of a type I hypersensitivity reaction? a. White blood cell count, 8900/mm3 b. Eosinophils, 10% c. Neutrophils, 65% d. Hemoglobin, 14 g/dL
B An increase in eosinophils indicates an allergic reaction (type I) or allergic rhinitis. Normal eosinophil count is 1% to 2%. The other laboratory values are normal. DIF: Cognitive Level: Application/Applying or higher
N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Implementation) 10. A client has angioedema of the lower face. What will the nurse assess next? a. Pulse oximetry b. Airway patency c. Breath sounds d. Chest wall symmetry
B Angioedema of the lower face includes the mouth and can rapidly lead to laryngeal edema and obstruction of the airway. Other assessments of the clients respiratory status could be done after the airway is assessed, such as pulse oximetry, breath sounds, and chest symmetry. DIF: Cognitive Level: Application/Applying or higher
N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlAccident/Injury Prevention) MSC: Integrated Process: Nursing Process (Implementation) 1. The nurse provides discharge instructions to a patient who has an immune deficiency involving the T lymphocytes. Which screening should the nurse include in the teaching plan for this patient? a. Screening for allergies b. Screening for malignancy c. Antibody deficiency screening d. Screening for autoimmune disorders
B Cell-mediated immunity is responsible for the recognition and destruction of cancer cells. Allergic reactions, autoimmune disorders, and antibody deficiencies are mediated primarily by B lymphocytes and humoral immunity. DIF: Cognitive Level: Apply (application)
N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Nursing Process (Implementation) 3. What is most important for the nurse to teach the client with allergic rhinitis and glaucoma? a. If your heartbeat increases, be sure to contact your health care provider. b. Avoid allergy drugs containing pseudoephedrine or phenylephrine. c. Be sure to drink plenty of water with antihistamines. d. You should use an eye-moistening agent such as Restasis.
B Ephedrine, phenylephrine, and pseudoephedrine may cause vasoconstriction, increase blood pressure, and increase intraocular pressure. The client should avoid these drugs. An increased heart rate is not a reason to call the health care provider. The client may be thirstier when on allergy medications, or the client may need an eye-moistening agent, but these are not the most important things for the nurse to teach. DIF: Cognitive Level: Application/Applying or higher
N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationMedical Emergencies) MSC: Integrated Process: Nursing Process (Implementation) 7. Which client characteristic places her or him at high risk for latex hypersensitivity? a. Allergy to shellfish b. History of spina bifida c. Total hip replacement d. Taking oral contraceptives
B People who have spina bifida have lifelong exposure to latex products and frequently develop latex hypersensitivities. An allergy to shellfish does not put a person at increased risk for latex allergies. A total hip replacement will not place a client at risk for latex hypersensitivity, nor does use of oral contraceptives. DIF: Cognitive Level: Comprehension/Understanding
216 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 9. The nurse teaches a patient diagnosed with systemic lupus erythematosus (SLE) about plasmapheresis. What instructions about plasmapheresis should the nurse include in the teaching plan? a. Plasmapheresis will eliminate eosinophils and basophils from blood. b. Plasmapheresis will remove antibody-antigen complexes from circulation. c. Plasmapheresis will prevent foreign antibodies from damaging various body tissues. d. Plasmapheresis will decrease the damage to organs caused by attacking T lymphocytes.
B Plasmapheresis is used in SLE to remove antibodies, antibody-antigen complexes, and complement from blood. T lymphocytes, foreign antibodies, eosinophils, and basophils do not directly contribute to the tissue damage in SLE. DIF: Cognitive Level: Understand (comprehension)
N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Interactions/Side Effects) MSC: Integrated Process: Nursing Process (Implementation) 4. A client has received diphenhydramine (Benadryl) and is currently oriented but drowsy. What is the best action for the nurse to take? a. Perform a neurologic assessment every 2 hours. b. Document the response and continue to monitor. c. Prepare to administer epinephrine subcutaneously. d. Have the nursing assistant stimulate the client every hour.
B The client is experiencing normal side effects of the medication. The nurse will continue to monitor for additive effects. Performing a neurologic assessment is not necessary, nor is administration of epinephrine. There is no reason for the client to be stimulated hourly. DIF: Cognitive Level: Application/Applying or higher
349 KEY: Infection| inflammation| white blood cell count| allergic response| histamine blockers| decongestants| patient education MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 1. Which characteristic is common to all types of hypersensitivity reactions? a. Decreased inflammatory responses b. Presence of tissue-damaging reactions c. Enhanced natural killer cell activity d. Inability to recognize extraneous cells
B The defining difference between a normal immune response and that termed hypersensitivity is that the immune system reacts excessively or inappropriately, with resultant tissue damage and pathology. DIF: Cognitive Level: Knowledge/Remembering
210 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 20. A patient who is anxious and has difficulty breathing seeks treatment after being stung by a wasp. What is the nurses priority action? a. Have the patient lie down. b. Assess the patients airway. c. Administer high-flow oxygen. d. Remove the stinger from the site.
B The initial action with any patient with difficulty breathing is to assess and maintain the airway. The other actions also are part of the emergency management protocol for anaphylaxis, but the priority is airway maintenance. DIF: Cognitive Level: Apply (application)
223-224 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 14. An adolescent patient seeks care in the emergency department after sharing needles for heroin injection with a friend who has hepatitis B. To provide immediate protection from infection, what medication will the nurse administer? a. Corticosteroids b. Gamma globulin c. Hepatitis B vaccine d. Fresh frozen plasma
B The patient should first receive antibodies for hepatitis B from injection of gamma globulin. The hepatitis B vaccination series should be started to provide active immunity. Fresh frozen plasma and corticosteroids will not be effective in preventing hepatitis B in the patient. DIF: Cognitive Level: Apply (application)
p. 391 TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 6. A client is receiving an IV infusion of an antibiotic. The client calls the nurse about feeling uneasy and uncomfortable owing to congestion. Which action by the nurse is most appropriate? a. Elevate the head of the clients bed to 45 degrees. b. Have another nurse call the Rapid Response Team. c. Prepare to administer diphenhydramine (Benadryl). d. Slow the rate of the IV infusion.
B This client has early signs of anaphylaxis. The nurse must notify the Rapid Response Team but also needs to stay with the client in case of cardiovascular collapse. The nurses best action is to ask another nurse to call the Team while he or she continues to assess the client. The nurse will prepare to administer epinephrine. Slowing the IV rate will not help the situation; if the client is reacting to the antibiotic, the nurse should change the IV tubing and solution. If the client is not hypotensive, the nurse can raise the head of the bed. DIF: Cognitive Level: Application/Applying or higher
352 KEY: Allergic response| communication| patient safety| immune disorders MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. 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? a. Administering steroids for severe serum sickness b. Correctly identifying the client prior to a blood transfusion c. Keeping the client free of the offending agent d. Providing a latex-free environment for the client
B 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. DIF: Applying/Application
356 KEY: Hypersensitivities| immunity| antibodies| antihistamines MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 6. A client with Sjgrens syndrome reports dry skin, eyes, mouth, and vagina. What nonpharmacologic comfort measure does the nurse suggest? a. Frequent eyedrops b. Home humidifier c. Strong moisturizer d. Tear duct plugs
B A humidifier will help relieve many of the clients Sjgrens syndrome symptoms. Eyedrops and tear duct plugs only affect the eyes, and moisturizer will only help the skin. DIF: Understanding/Comprehension
352 KEY: Allergic response| epinephrine| patient education MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Health Promotion and Maintenance 9. A client having severe allergy symptoms has received several doses of IV antihistamines. What action by the nurse is most important? a. Assess the clients bedside glucose reading. b. Instruct the client not to get up without help. c. Monitor the client frequently for tachycardia. d. Record the clients intake, output, and weight.
B Antihistamines can cause drowsiness, so for the clients 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. DIF: Applying/Application
355 KEY: Hypersensitivities| inflammation| immunity| autoimmune disorder MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 4. 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
B The creatinine is high, possibly indicating the client has serum sickness nephritis. Blood urea nitrogen and white blood cell count are both normal. Hemoglobin is not related. DIF: Analyzing/Analysis
N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Implementation) 11. A mother brings her child to the clinic requesting genetic testing to determine whether her child suffers from the same multiple allergies as herself. What action by the nurse is most appropriate? a. Provide a referral to an allergist so the child can be tested. b. Refer the mother to a geneticist for genetic testing on the child. c. Ask the mother about specific symptoms the child may have had. d. Have the mother list her allergies and the symptoms they cause her.
C Allergic tendencies can be inherited, but no single gene has been identified that causes allergies, and allergies to specific items are not inherited. The nurse should ask the mother about any symptoms the child has that seem related to allergies. The child will not be tested by an allergist simply because the mother has allergies, and a geneticist will not be able to identify an allergy gene in the child. Because specific allergies are not inherited, having the mother list her allergies will not be beneficial. DIF: Cognitive Level: Application/Applying or higher
N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Analysis) 17. An unknown unconscious client with an elevated temperature is ordered intravenous penicillin. What is the best action for the nurse to take? a. Administer the medication. b. Check the chart for allergies. c. Look for medical alert identification. d. Notify the nursing supervisor.
C Allergies need to be identified before medications are administered. This client cannot talk and is unknown, so a chart cannot be retrieved. Clients with allergies are taught to carry medical alert identification. DIF: Cognitive Level: Application/Applying or higher
213-214 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 23. The health care provider asks the nurse whether a patients angioedema has responded to prescribed therapies. Which assessment should the nurse perform? a. Ask the patient about any clear nasal discharge. b. Obtain the patients blood pressure and heart rate. c. Check for swelling of the patients lips and tongue. d. Assess the patients extremities for wheal and flare lesions.
C Angioedema is characterized by swelling of the eyelids, lips, and tongue. Wheal and flare lesions, clear nasal drainage, and hypotension and tachycardia are characteristic of other allergic reactions. DIF: Cognitive Level: Apply (application)
209 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 5. A patient who collects honey to earn supplemental income has developed a hypersensitivity to bee stings. Which statement, if made by the patient, would indicate a need for additional teaching? a. I need to find another way to earn extra money. b. I will get a prescription for epinephrine and learn to self-inject it. c. I will plan to take oral antihistamines daily before going to work. d. I should wear a Medic-Alert bracelet indicating my allergy to bee stings.
C Because the patient is at risk for bee stings and the severity of allergic reactions tends to increase with added exposure to allergen, taking oral antihistamines will not adequately control the patients hypersensitivity reaction. The other patient statements indicate a good understanding of management of the problem. DIF: Cognitive Level: Apply (application)
213-214 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 7. The nurse, who is reviewing a clinic patients medical record, notes that the patient missed the previous appointment for weekly immunotherapy. Which action by the nurse is most appropriate? a. Schedule an additional dose that week. b. Administer the usual dosage of the allergen. c. Consult with the health care provider about giving a lower allergen dose. d. Re-evaluate the patients sensitivity to the allergen with a repeat skin test.
C Because there is an increased risk for adverse reactions after a patient misses a scheduled dose of allergen, the nurse should check with the health care provider before administration of the injection. A skin test is used to identify the allergen and would not be used at this time. An additional dose for the week may increase the risk for a reaction. DIF: Cognitive Level: Apply (application)
208 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 2. A new mother expresses concern about her baby developing allergies and asks what the health care provider meant by passive immunity. Which example should the nurse use to explain this type of immunity? a. Early immunization b. Bone marrow donation c. Breastfeeding her infant d. Exposure to communicable diseases
C Colostrum provides passive immunity through antibodies from the mother. These antibodies protect the infant for a few months. However, memory cells are not retained, so the protection is not permanent. Active immunity is acquired by being immunized with vaccinations or having an infection. It requires that the infant has an immune response after exposure to an antigen. Cell-mediated immunity is acquired through T lymphocytes and is a form of active immunity. DIF: Cognitive Level: Apply (application)
221 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 25. A patient who is receiving immunotherapy has just received an allergen injection. Which assessment finding is most important to communicate to the health care provider? a. The patients IgG level is increased. b. The injection site is red and swollen. c. The patients allergy symptoms have not improved. d. There is a 2-cm wheal at the site of the allergen injection.
D A local reaction larger than quarter size may indicate that a decrease in the allergen dose is needed. An increase in IgG indicates that the therapy is effective. Redness and swelling at the site are not unusual. Because immunotherapy usually takes 1 to 2 years to achieve an effect, an improvement in the patients symptoms is not expected after a few months. DIF: Cognitive Level: Apply (application)
221-222 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 16. An older adult patient has a prescription for cyclosporine following a kidney transplant. Which information in the patients health history has the most implications for planning patient teaching about the medication at this time? a. The patient restricts salt to treat prehypertension. b. The patient drinks 3 to 4 quarts of fluids every day. c. The patient has many concerns about the effects of cyclosporine. d. The patient has a glass of grapefruit juice every day for breakfast.
D Grapefruit juice can increase the toxicity of cyclosporine. The patient should be taught to avoid grapefruit juice. High fluid intake will not affect cyclosporine levels or renal function. Cyclosporine may cause hypertension, and the patients many concerns should be addressed, but these are not potentially life-threatening problems. DIF: Cognitive Level: Apply (application)
349 KEY: Immunity| immune disorders| immunoglobulins| inflammation MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. 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: Physical Assessment Data Laboratory Results Reports sore throat, runny nose, headache Posterior pharynx is reddened Nasal discharge is seen in the back of the throat Nasal discharge is creamy yellow in color Temperature 100.2 F (37.9 C) Red, watery eyes White blood cell count: 13,400/mm3 Eosinophil count: 11.5% Neutrophil count: 82% 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
B, C, D, E This client has manifestations of both allergic rhinitis and an overlying infection (probably sinus, as evidenced by purulent nasal drainage, high white blood cells, and high neutrophils). The client needs education on antihistamines such as chlorpheniramine, future allergy testing, the proper way to use decongestant nasal sprays, and ensuring that the full dose of antibiotics is taken. Since the nurse does not yet know what the client is allergic to, advising him or her to get rid of pets is premature. DIF: Analyzing/Analysis
N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care-Establishing Priorities) MSC: Integrated Process: Nursing Process (Implementation) MULTIPLE RESPONSE 1. A client is admitted for a cardiac catheterization. It is essential for the nurse to ask the client about which allergies? (Select all that apply.) a. Penicillin b. Latex c. Iodine d. Shellfish e. Keflex f. Dilantin g. Bananas
B, C, D, G It is important to check for all allergies, but for a cardiac catheterization, the nurse needs to question about shellfish, iodine, latex, and bananas specifically. The contrast used contains iodine, and the equipment in the laboratory frequently contains latex. Information concerning these allergies needs to be passed on to laboratory personnel before the client goes to the laboratory. This will prevent the client from having an anaphylactic reaction during the procedure. DIF: Cognitive Level: Application/Applying or higher