MS Exam 4: Chapter 20

what should you educate your patient on regarding care and use of automatic epinephrine injectors?

-practice assembly of injection device with a non-drug-containing training device provided through the injection device manufacturer -keep the device with you at all times -when needed, inject the drug into the top of your thigh, slightly to the outside, holding the device so the needle enters straight down -you can inject the drug right through your pants; just avoid seams and pockets where the fabric is thicker -use the device when any symptom of anaphylaxis is present and call 911. it is better to use the drug when it is not needed than to not use it when it is needed -whenever you need to use the device, get to the nearest hospital for monitoring for at least the next 4-6 hours -have at least 2 drug filled devices on hand in case more than one dose is needed -protect the device from light and avoid temperature extremes -carry the device in the case provided by the manufacturer -keep the safety cap in place until you are ready to use the device -check the device for the expiration date, drug clarity (should not be discolored), and security of cap (should not be loose or come off accidentally

Which interventions apply in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply. 1. Use non-latex gloves. 2. Use medications from glass ampules. 3. Place the client in a private room only. 4. Keep a latex-safe supply cart available in the client's area. 5. Avoid the use of medication vials that have rubber stoppers. 6. Use a blood pressure cuff from an electronic device only to measure the blood pressure.

1, 2, 4, 5

When preparing a client for allergy testing, the nurse provides the client with which instruction? a. "Antihistamines should be discontinued 2 weeks before the test to avoid suppressing the test response." b. "It is okay to use your fluticasone propionate (Flonase) nasal spray before testing." c. "Aspirin in a low dose may be taken before testing." d. "You can take antihistamine nasal sprays before testing."

A

which questions are most important for the nurse to first ask a client who comes to the ED with signs of severe angioedema? select all that apply. a. are you able to swallow? b. when did you last eat or drink? c. do you have an allergy to cortisone? d. what drugs do you take on a daily basis? e. is there any possibility that you may be pregnant? f. do any members of your family also have allergies?

A, D

what are the physical symptoms of anaphylaxis?

-Blood vessel dilation -Decreased cardiac output -Bronchoconstriction

what is a type 1 hypersensitivity reaction?

- immediate hypersensitivty (allergic rxn) - mediated primarily by Immunoglobulin E ab - acute and life threatening -Caused by increased production of immunoglobulin E (IgE) antibody class -Exposure agent can be inhaled, ingested, injected, or come in contact with skin or mucus membranes -Re-exposure causes an allergic response (range is runny nose and eyes to anaphylaxis)

what is the immunosuppressive therapy for autoimmunity?

-There is no cure for an autoimmune disease -Corticosteroids -Cytotoxic drugs -Selective immunosuppressive therapy -Antiproliferative drugs -Calcineurin inhibitors -Disease-modifying antirheumatic drugs

what do you need to know about latex allergies?

-Type I hypersensitivity reaction -Protein found in natural latex rubber products is specific allergen -Allergen causes interaction with IgE -Incidence of latex allergy is increasing -Health care workers especially susceptible -BP cuff tubes are latex, most stethoscopes are latex, there is latex in glue (candy bars, bandages, tires) -Remove everything from the room that has latex -Do a latex screen on admission -When you blow up balloons, do you get a rash on your lips, any problems at the dentist, any food allergies?

how is epinephrine used for angioedema?

-1 to 1,000 concentration -give 0.3-0.5 mL -can be given IV or IM every 5-15 minutes until the patient responds -dilates bronchioles and constricts blood vessels to improve cardiac function

before drug therapy, what are some other interventions for allergies?

-Avoidance therapy -Environmental changes: air-conditioning, air-cleaning units, cloth drapes, upholstered furniture, and carpeting -Pet interventions

what is autoimmunity?

-Development of an inappropriate immunity -Antibodies/lymphocytes directed against healthy normal cells and tissues (autoantibodies) -Immune system fails to recognize certain body cells/tissues as self, triggers immune reactions

what is an immune complex reaction (type 3)?

-Excess antigens cause immune complexes to form in blood -Circulating complexes lodge in small blood vessels -Usual sites: Kidneys, skin, joints** -Deposited complexes trigger inflammation, resulting in tissue or vessel damage

what are clinical examples of a cytotoxic reaction?

-Hemolytic anemias -Immune thrombocytopenic purpura -Hemolytic transfusion reactions -Goodpasture's syndrome -Drug-induced hemolytic anemia

what are allergies/hypersensitivities?

-Increased/excessive response to presence of antigen exposure -Degree of reaction ranges from uncomfortable (itchy, watery eyes; sneezing) to life threatening (allergy asthma, angioedema, anaphylaxis- shock, bronchoconstriction, circulatory collapse) -Overactive immunity with inflammation occurring in response to an antigen to which the patient usually has had a previous exposure

how are allergens contracted?

-Inhalation (pollens, spores, animal dander, dust, grass, ragweed) -Ingestion (foods, food additives, drugs) -Injection (bee venom, drugs, biologic substances) -Contraction (latex, pollens, foods, environmental proteins)

how should you teach your patients to prevent anaphylaxis?

-Medical alert bracelet -Notify health care personnel about specific allergies -Carry anaphylaxis kit or epinephrine injector -Medical records should prominently display list of specific allergens -Precautionary measures if drug or agent must be used despite history of allergic reaction

what are the airborne allergens that trigger allergic rhinitis?

-Plant pollens -Molds -Dust -Animal dander -Wool -Food -Air pollutants

what are some examples of a delayed hypersensitivity reaction?

-Positive purified protein derivative -Contact dermatitis -Poison ivy skin rashes -Local response to insect stings -Tissue transplant rejection -Sarcoidosis

what is a delayed hypersensitivity reaction (type 4)?

-Reactive cell is T-lymphocyte (T-cell) -Antibodies and complement not involved -Local collection of lymphocytes and macrophages causes edema, induration, ischemia, tissue damage at site

what are some examples of an immune complex reaction?

-Rheumatoid arthritis -Systemic lupus erythematosus

what is the drug therapy for allergies?

-Steroidals and non-steroidals (anti-inflammatory properties) -Decongestants (consult MD with HTN- contraindicated, urinary retention, glaucoma) -Antihistamines -Mast cell stabilizers -Leukotriene antagonists

what are the key features of anaphylaxis (angioedema)?

-dyspnea -bronchospasms -wheezes -stridor -hypoxia -cyanosis -peak expiratory rate flow lower than the patient's usual rate -hypotension -loss of consciousness -incontinence -hypoxia (shift from intravascular space to third spacing) -absent deep tendon reflexes -feeling of impending doom

how should you care for a patient experiencing anaphylaxis?

-immediately assess the respiratory status, airway, and oxygen saturation of patients who show any symptom of an allergic reaction -call the rapid response team -ensure that intubation and tracheostomy equipment is ready -apply oxygen using a high-flow, nonrebreather mask at 90% to 100% -immediately discontinue the IV drug or infusing solution of a patient having an anaphylactic reaction to that drug or solution. do not discontinue the IV, but change the IV tubing and hang NS -if the patient does not have an IV, start one immediately and run NS -be prepared to administer epinephrine IV or IM -keep the HOB elevated about 10 degrees if hypotension is present; if BP is normal, elevate the HOB to 45 degrees or higher to improve ventilation -raise the feet and legs -stay with the patient -reassure the patient that the appropriate interventions are being instituted

how are corticosteroids used for angioedema?

-patients may be sent on an oral tapering pack -IV Solu-Medrol is used during angioedema

1.Based on the patient's history of new onset of shortness of breath and edema of the eyes and lips, what does the nurse suspect is the problem? 2.What questions are appropriate to ask this patient?

1. The nurse anticipates that the patient may be having an anaphylactic reaction. The patient stated that she has a peanut allergy. These have been linked to contact with latex. 2. Because the patient had been working prior to presenting to the ED, the nurse should inquire about her use of latex gloves during her shift, and ask her about any procedures she may have performed before the symptoms developed. Anaphylaxis is the most dramatic and life-threatening example of type I hypersensitivity reaction; it occurs rapidly and systemically.

The nurse is reviewing discharge teaching with a client who suffered an anaphylactic reaction to a bee sting. Which statement by the client indicates the need for further teaching? a. "I must wear a medical alert bracelet stating that I am allergic to bee stings." b. "I need to carry epinephrine with me." c. "My spouse must learn how to give me an injection." d. "I am immune to bee stings now that I have had a reaction."

D

The nurse is reviewing the medical record of a client who is prescribed a decongestant. The nurse plans to contact the client's health care provider if the client has which condition? a. Cataracts b. Crohn's disease c. Diabetes mellitus d. Hypertension

D

The nurse prepares to administer zafirlukast (Accolate) to a client with allergic rhinitis. Zafirlukast works by which mechanism? a. Blocking histamine from binding to receptors b. Preventing synthesis of mediators c. Preventing mast cell membranes from opening d. Blocking the leukotriene receptor

D

Which nursing action is most appropriate for the nurse working in an allergy clinic to delegate to a nursing assistant? a. Plan the schedule for desensitization therapy for a client with allergies. b. Monitor the client who has just received skin testing for signs of anaphylaxis. c. Educate a client with a latex allergy about other substances with cross-sensitivity to latex. d. Remind the client to stay at the clinic for 30 minutes after receiving intradermal allergy testing.

D

The student nurse is listening to a lecture on the different types of allergic reactions. Which statement by the student nurse indicates that teaching has been effective? 1. "Atopic allergic reactions are the most life threatening." 2. "Hemolytic allergic reactions are the most life threatening." 3. "Anaphylaxis is the most life-threatening allergic reaction." 4. "Hypersensitivity is the most life-threatening allergic reaction."

3

how is Benadryl (diphenhydramine) used for angioedema?

give 25-100 mg IV or IM

what is allergic rhinitis also referred to as?

hay fever

what are the indications for intubation with angioedema?

the presence of stridor and the inability of the patient to swallow

A client recently admitted to the hospital with a UTI is to receive the first dose of an antibiotic intravenously. Before checking the five rights prior to administration, what is the nurse's first action? a. Review the clinical records and ask the client about any known allergies. b. Check with the pharmacy for any known allergies for this client. c. Check the client's identification band for any allergies. d. Ask the nurse who previously cared for the client about any known allergies.

A

A client with a history of asthma is admitted to the clinic for allergy testing. During skin testing, the client develops shortness of breath and stridor and becomes hypotensive. What is the most appropriate drug for the nurse to give in this situation? a. Epinephrine (Adrenalin) b. Fexofenadine (Allegra) c. Cromolyn sodium (Nasalcrom) d. Zileuton (Zyflo)

A

A patient has been admitted to the ED with bilateral eyelid swelling and subsequent difficulty seeing. What is the priority nursing assessment? A. Airway B. Nasal cavity C. Home medications D. History of visual disturbances

A

The nurse has educated the patient with a shellfish allergy about signs and symptoms of angioedema. Which patient statement requires further nursing education? A. "I can eat shrimp because it is not a shellfish." B. "There is an epinephrine injector in my purse at all times." C. "Symptoms of angioedema include swelling of eyes, lips, and tongue." D. "When I see a new physician, I will report that I have a shellfish allergy."

A

how should you care for patients with allergies?

•Allergy documentation is important •Drugs: use decongestants, intranasal steroid spray, antihistamines for type 1 allergies •Immunotherapy: allergy shots (given in OPA setting, make sure you have epinephrine and way to maintain patent airways before giving allergy shots)

A client is prescribed prednisone for treatment of a type I hypersensitivity reaction. The nurse plans to monitor the client for which adverse effects? Select all that apply. a. Fluid retention b. Gastric distress c. Hypotension d. Infection e. Osteoporosis

A, B, D, E

What therapies does the nurse anticipate the provider will order? (Select all that apply.) A. Epinephrine (Adrenalin) B. Diphenhydramine (Benadryl) C. Acetaminophen (Tylenol) D. IV fluids E. Oxygen

A, B, D, E

The nurse is assessing a client with suspected serum sickness. Which symptoms are consistent with serum sickness? Select all that apply. a. Arthralgia b. Blurred vision c. Lymphadenopathy d. Malaise e. Ptosis

A, C, D

what are the drugs most commonly associated with angioedema?

ACEIs and NSAIDs

what are the appropriate interventions for angioedema?

•Intervene promptly (if they develop laryngeal edema, need intubated- need a trach kit available) •Meds: epinephrine, diphenhydramine (Benadryl), and corticosteroids •Even if we see symptoms reversed, need to keep IV access for another 2-6 hours •Might use albuterol for bronchospasms •Reassure the patient and explain what you are doing, use continuous pulse ox, assure them that the proper treatment is occurring and that the medication will resolve the swelling

what is a cytotoxic reaction (type 2)?

Body makes special autoantibodies directed against self cells that have some form of foreign protein attached to them

A client is being discharged from the hospital after an allergic reaction to environmental airborne allergens. Which instruction is most important for the nurse to include in this client's discharge teaching plan? a. Wash fruits and vegetables with mild soap and water before eating. b. Intermittent exposure to known allergens will produce immunity. c. Remove cloth drapes, carpeting, and upholstered furniture. d. Be cautious when eating unprocessed honey.

C

A patient comes to the ED with shortness of breath and facial edema, reporting rhinorrhea (runny nose) and a severe headache. The triage nurse notes that the patient's lips and eyes are very swollen. What assessment history questions should be asked at this time?

An accurate and detailed history is important. The patient should be asked to describe the onset and duration of problems related to possible allergen exposure. Ask about work, school, and home environments and possible exposures through hobbies, leisure, or sports activities. The patient should also be asked about the presence of allergies among close relatives because of the tendency for type I allergies to be inherited.

A client who is receiving an intravenous antibiotic begins to cough and states, "My throat feels like it is swelling." Which action does the nurse take next? a. Infuse normal saline at 200 mL/hr. b. Administer epinephrine (Adrenalin) 1:1000, 0.3 mL subcutaneously. c. Discontinue infusing the antibiotic. d. Give diphenhydramine (Benadryl) 100 mg IV.

C

Assessment findings reveal that a client admitted to the hospital has a contact type I hypersensitivity to latex. Which preventive nursing intervention is best in planning care for this client? a. Report the need for desensitization therapy. b. Convey the need for pharmacologic therapy to the health care provider. c. Communicate the need for avoidance therapy to the health care team. d. Discuss symptomatic therapy with the health care provider.

C

The nurse plans to assess a client with type I hypersensitivity for which clinical manifestation? a. Poison ivy b. Autoimmune hemolytic anemia c. Allergic asthma d. Rheumatoid arthritis

C

what is angioedema?

•Severe type 1 hypersensitivity •Often seen in the lips, face, tongue, larynx, and neck •Might only have a little bit of lip swelling after the first exposure then full angioedema after next exposure •Reaction is 24 hours after exposure up to years •Deep, firm swelling •Patient may have difficulty speaking or drinking, may distort the face, too much swelling or nares can result in trouble breathing through the nose, hives may be present, may need intubated if they are unable to swallow, develop a lump in their throat, or develop stridor •Patients are scared

A client has been ordered norepinephrine (Levophed) for treatment of severe hypotension. The nurse plans to monitor the client for which adverse effect? a. Bradycardia b. Headache c. Infection d. Metabolic alkalosis

B

A client is admitted to the hospital with suspected Goodpasture's syndrome. Which findings does the nurse expect to observe? a. Bradycardia b. Hemoptysis c. Increased urine output d. Weight gain

B

A nurse is administering a new medication intravenously to a patient. The patient becomes short of breath and begins to experience itching and hives. What is the priority nursing response? A. Assess blood pressure B. Stop the intravenous infusion C. Discuss anxiety with the patient D. Review the patient's allergies

B

The nursing instructor asks the student nurse to explain a type IV hypersensitivity reaction. Which statement by the student best describes type IV hypersensitivity? a. "It is a reaction of immunoglobulin G (IgG) with the host cell membrane or antigen." b. "The reaction of sensitized T cells with antigen and release of lymphokines activate macrophages and induce inflammation." c. "It results in release of mediators, especially histamine, because of the reaction of immunoglobulin E (IgE) antibody on mast cells." d. "An immune complex of antigen and antibodies is formed and deposited in the walls of blood vessels."

B

The nurse asks the patient if she has any allergies. The patient states that she has an allergy to peanuts, but has not had anything to eat today. The patient also states that she worked earlier today as a nursing assistant. Which laboratory tests does the nurse anticipate the provider will order? (Select all that apply.) A. Electrolytes B. Immunoglobulin E C. CBC with differential D. Liver function tests (LFT) E. Kidney function tests (KFT)

B, C

what is the mechanism of a type 1 reaction (immediate)?

Reaction of IgE antibody on mast cells with antigen, which results in release of mediators, especially histamine

what is the mechanism of a type 2 reaction (cytotoxic)?

Reaction of IgG with host cell membrane or antigen adsorbed by host cell membrane

what is the mechanism of a type 4 reaction (delayed)?

Reaction of sensitized T-cells with antigen and release of lymphokines, which activates macrophages and induces inflammation

An alert, middle-aged client is admitted to the emergency department with wheezing, difficulty breathing, angioedema, blood pressure of 70/52 mm Hg, and apical pulse of 122 beats/min and irregular. The nurse makes an immediate assessment using the "ABCs" for any client experiencing anaphylaxis. What nursing intervention is the immediate priority? a. Raise the lower extremities. b. Start intravenous (IV) administration of normal saline. c. Reassure the client that appropriate interventions are being instituted. d. Apply oxygen using a high-flow non-rebreather mask at 40% to 60%.

D

Five minutes later, the patient continues to experience shortness of breath. She states that she is feeling anxious and frightened. What is the appropriate nursing intervention? A. Reassure the patient that all will be well. B. Prepare the patient for a stat chest x-ray. C. Ask the provider to prescribe an anti-anxiety drug. D. Assess the patient for signs of respiratory distress.

D

A client in the allergy clinic develops all of these clinical manifestations after receiving an intradermal injection of an allergen. Which symptom requires the most immediate action by the nurse? a. Anxiety b. Urticaria c. Pruritus d. Stridor

D

The client with a history of asthma is prescribed a leukotriene receptor antagonist to prevent allergic rhinitis. The nurse anticipates that which drug will be prescribed? a. Cromolyn sodium (Nasalcrom) b. Desloratadine (Clarinex) c. Fexofenadine (Allegra) d. Zafirlukast (Accolate)

D

what is the mechanism of a type 3 reaction (immune complex mediated)?

Formation of immune complex of antigen and antibody, which deposits in walls of blood vessels and results in complement release and inflammation

what is the drug alert box for all anti-proliferative drugs?

all anti-proliferative drugs are associated with poor pregnancy outcomes, and pregnancy is an absolute contraindication for their use. Teach sexually active women in childbearing years to use 2 reliable methods of contraception during therapy with anti-proliferatives and for 12 weeks after they are discontinued. Breastfeeding while taking these drugs is also contraindicated.

what is the drug alert box for all selective immunosuppressants?

all selective immunosuppressants reduce protective immunity to some degree and increase the patient's risk for new infections and reactivation of dormant infections such as tuberculosis. These drugs are not to be started on any patient with a current infection. Tuberculosis testing is usually performed before starting any selective immunosuppressant. Teach patients taking these drugs to avoid crowds and people who are ill. Also teach them to contact their primary health care provider at the first sign of infection.