(2) Allergy and Anaphylaxis
"The charge nurse observes the primary nurse interacting with a client. Which action by the primary nurse warrants immediate intervention by the charge nurse? 1. The nurse explains the IVP diuretic will make the client urinate. 2. The nurse dons nonsterile gloves to remove the client's dressing. 3. The nurse administers a medication without checking for allergies. 4. The nurse asks the UAP for help moving a client up in bed."
"1. This is appropriate anytime the nurse is administering a diuretic medication. 2. A nurse uses nonsterile gloves to remove old dressings, then washes the hands and sets up the sterile field before donning sterile gloves to reapply the dressing. *3. Checking for allergies is one (1) of the five (5) rights of medication. Is it the right drug? Even if the drug is the one the HCP ordered, it is not the right drug if the client is allergic to it. The nurse should always assess a client's allergies prior to administering any medication. 4. The nurse should ask for assistance in moving a client in bed to prevent on-thejob injuries. TEST-TAKING HINT: The stem asks the test taker to determine which is an incorrect action. This is an ""except"" question. Three (3) answers are actions the nurse should take."
Which assessment data should make the nurse suspect the client has chronic allergies? 1. Jaundiced sclera and jaundiced palms of hands. 2. Pale, boggy, edematous nasal mucosa. 3. Lacy white plaques on the oral mucosa. 4. Purple or blue patches on the face.
"1. This may indicate a hemolytic reaction. *2. Pale, boggy, edematous nasal mucosa indicates chronic allergies. 3. This may indicate hemolysis or immune deficiency. 4. This may indicate Kaposi's sarcoma."
"Anaphylactic shock can occur due to either an immunological or non-immunological cause. Select ALL the CORRECT statements about the differences between an immunological reaction (anaphylactic) and non-immunological reaction (anaphylactoid):* A. ""In an immunological reaction (anaphylactic) IgE antibodies are created and they attach to mast cells and basophils."" B. ""An immunological reaction (anaphylactic) requires a patient to be sensitized for anaphylactic shock to occur."" C. ""A non-immuno
"A. ""In an immunological reaction (anaphylactic) IgE antibodies are created and they attach to mast cells and basophils."" B. ""An immunological reaction (anaphylactic) requires a patient to be sensitized for anaphylactic shock to occur."" D. ""Some common substances that cause a non-immunological reaction (anaphylactoid) are IV contrast dyes and NSAIDS."" E. ""A patient does not have to be sensitized for a non-immunological reaction (anaphylactoid) to occur and it can happen with first time exposure."""
"The nurse is providing discharge teaching for a teenager who has experienced anaphylaxis related to a food allergy. Which statement by the nurse addresses the most common risk factor for an allergic reaction in a teenager? A. ""eat nutritional meals and drink plenty of fluids."" B. ""Monitor what you are eating outside the home."" C. Seek emergency medical help if you feel you have experiencing anaphylaxis."" D. ""limit your exposure to the food that caused the reaction."""
"B. ""Monitor what you are eating outside the home."""
"You're providing education to a patient, who has a severe peanut allergy, on how to recognize the signs and symptoms of anaphylactic shock. Select all the signs and symptoms associated with anaphylactic shock:* A. Hyperglycemia B. Difficulty speaking C. Feeling dizzy D. Hypertension E. Dyspnea F. Itchy G. Vomiting and Nausea H. Fever I. Slow heart rate"
"B. Difficulty speaking C. Feeling dizzy E. Dyspnea F. Itchy G. Vomiting and Nausea Patients who are in anaphylactic shock will have signs and symptoms associated with the effects of histamine. Remember histamine affects the respiratory, cardiac, GI and skin. The patient can have the following: Respiratory: dyspnea and wheezing (bronchoconstriction), swelling of upper airways due to edema ""tightness""...can't speak, coughing, stuffy nose, watery eyes, Cardiac: tachycardia, hypotension (vasodilation)...loss of consciousness, dizzy, GI: vomiting, nausea, pain, Skin: vasodilation...red, swollen, itchy, hives"
"You're providing care to a patient in anaphylactic shock. What is NOT a typical medical treatment for this condition, and if ordered the nurse should ask for an order clarification?* A. IV Diphenhydramine B. Epinephrine C. Corticosteroids D. Isotonic intravenous fluids E. IV Furosemide"
"E. IV Furosemide Furosemide is a loop-diuretic. This medication removes extra fluid from the blood volume. This is NOT used as treatment in anaphylactic shock. Patients with this condition actually need fluids because of the shift of fluid from the intravascular space to the interstitial space. All the other medications may be ordered for this condition depending on the patient's condition."
The client has had an anaphylactic reaction to insect venom, a bee sting. Which discharge instruction should the nurse discuss with the client? 1. Take a corticosteroid dose pack when stung by a bee. 2. Take antihistamines prior to outdoor activities. 3. Use a cromolyn sodium (Intal) inhaler prophylactically. 4. Carry a bee sting kit, especially when going outside.
1. Corticosteroids may be used in both systemic and topical forms for many types of hypersensitivity responses, but must be ordered by a health-care provider and are not automatically taken after a bee sting. 2. Antihistamines are the major class of drugs used to treat hypersensitivity responses, but they are not taken prophylactically. They are used when a reaction occurs. 3. This drug treats allergic rhinitis and asthma prophylactically. It does not help bee stings or insect bites. *4. The kit usually includes a prefilled syringe of epinephrine and an epinephrine nebulizer, which allows prompt self-treatment for any future exposures to insect venom or other potential allergen exposure.
"The nurse on a medical unit has received the morning shift report. Which client should the nurse assess first? 1. The client who has a 0730 sliding-scale insulin order. 2. The client who received an initial dose of IV antibiotic at 0645. 3. The client who is having back pain at a ""4"" on a 1-to-10 scale. 4. The client who has dysphagia and needs to be fed."
1. This client should be seen but not before assessing for a possible anaphylactic reaction. *2. This client has received an initial dose of antibiotic IV and should be assessed for tolerance to the medication within 30 minutes. 3. Pain is a priority but not over a potential life-threatening emergency. 4. This client can be seen last. A delayed meal is not life threatening. TEST-TAKING HINT: The test taker should determine which client has the most pressing need and rank the options in order. Life-threatening situations have priority.
The client is prescribed a prick epicutaneous test to determine the cause of hypersensitivity reactions. Which result indicates the client is hypersensitive to the allergen? 1. The client complains of shortness of breath. 2. The skin is dry, intact, and without redness. 3. The pricked blood tests positive for allergens. 4. A pruritic wheal and erythema occur.
1. This is a sign of an anaphylactic reaction to an allergen and will not happen during this test because of the small amount of allergen used. 2. This indicates a negative test and the client is not sensitive to the allergen. 3. The skin reaction, not the blood pricked, indicates a positive or negative test. *4. During this test, a drop of diluted allergenic extract is placed on the skin and then the skin is punctured through the drop. A positive test causes a localized pruritic wheal and erythema, which occurs in five (5) to 20 minutes.
"The client asks the nurse, ""Which time of the year is allergic rhinitis least likely to occur?"" Which statement is the nurse's best response? 1. ""It is least likely to occur during the springtime."" 2. ""Allergic rhinitis is not likely to occur during the summer."" 3. ""It is least likely to occur in the early fall."" 4. ""Allergic rhinitis is least likely to occur in early winter."""
1. Tree pollen is abundant in early spring. 2. Rose and grass pollen are prevalent in early summer. 3. Ragweed and other pollens are prevalent in early fall. *4. Early winter is the beginning of deciduous plants becoming dormant. Therefore, allergic rhinitis is least prevalent during this time of year. TEST-TAKING HINT: The test taker could eliminate the three (3) options based on the plant growing season if the test taker realized allergic rhinitis can be caused by environmental plant pollens and molds.
In performing a physical assessment on a client who is experiencing a hypersensitivity reaction, which findings should the nurse anticipate? (select all that apply) A. altered respiratory rate B. eyes with tearing and redness C. cold, moist skin D. Skin lesions or rashes E. Adventitious breath sounds
A. Altered respiratory rate B. eyes with tearing and redness D. Skin lesions or rashes E. Adventitious breath sounds
When planning care for a client admitted with a hypersensitivity reaction, the nurse addresses the potential problem of airway clearance. Which intervention will assistantships in addressing this potential problem? (Select all that apply) A. Assessing level of consciousness B. Administering oxygen C. Auscultating lung sounds D. Placing the client in a supine position e. Administering epinephrine
A. Assessing level of consciousness B. administering oxygen C. Auscultating lung sounds E. Administering epinephrine
The nurse is caring for a client who requires a course of oral steroids more than once a year for the treatment of asthma related to allergens. Which alternative therapy should the nurse anticipate being prescribe for the client to avoid the frequent use of steroids? A. Immunotherapy B. Omalizumab C. Plasmapheresis D. Antihistamines
A. Immunotherapy
Which nonpharmacologic treatments should the nurse suggest for the client who is experiencing seasonal allergic rhinitis due to the pollen in the air? (select all that apply) A. Remain indoors during the day B. Maintain a clean, dust-free environment C. Use special filters on the air conditioners D. Shower before exiting the house E. Keep doors and windows closed
A. Remain indoors during the day B. Maintain a clean, dust-free environment C. Use special filters on the air conditioners D. Keep doors and windows closed
The client is highly allergic to insect venom and is prescribed venom immunotherapy. Which statement is the scientific rationale for this treatment? 1. Immunotherapy is effective in preventing anaphylaxis following a future sting. 2. Immunotherapy will prevent all future insect stings from harming the client. 3. This therapy will cure the client from having any allergic reactions in the future. 4. This therapy is experimental and should not be undertaken by the client.
"*1. Immunotherapy does not cure the problem. However, if immunotherapy is done following a reaction, it provides passive immunity to the insect venom (similar to the way RhoGAM prevents a mother who is Rh negative from building antibodies to the blood of a baby who is Rh positive). This is the purpose for immunotherapy in clients who are allergic. 2. This is an untrue statement. 3. There is no cure for allergies to insect venom. 4. This therapy is standard procedure for clients who have severe allergies to insect venom. TEST-TAKING HINT: Answer options ""2"" and ""3"" contain forms of absolutes such as ""all"" and ""cure."" Rarely is anything absolute in health care. The test taker should be absolutely sure of the correct answer before choosing any answer containing an absolute descriptive word or passage. The stem asks for the rationale and option ""4"" is giving advice, so it can be eliminated."
"The client in the HCP's office is complaining of allergic rhinitis. Which assessment question is important for the nurse to ask the client? 1. ""What time of year do the symptoms occur?"" 2. ""Which over-the-counter medications have you tried?"" 3. ""Do other members of your family have allergies to animals?"" 4. ""Why do you think you have allergies?"""
"1. The symptoms are occurring at this time, so asking what time of the year the symptoms occur is not an appropriate question. *2. There are many over-the-counter remedies available. Therefore, the nurse should assess which medications the client has tried and what medications the client is currently taking. 3. The client being allergic to animals was not in the stem. Many clients diagnosed with allergic rhinitis are allergic to seasonal environmental allergens such as pollen and mold. 4. The client probably does not have any explanation for developing allergies. TEST-TAKING HINT: The test taker should not read into a question. Because animals were not mentioned in the stem, option ""3"" can be eliminated. Many over-the-counter medications and herbal remedies are available to clients, and it is important for the nurse to determine what the client has been taking."
The client comes to the emergency department complaining of dyspnea and wheezing after eating at a seafood restaurant. The client cannot speak and has a bluish color around the mouth. Which intervention should the nurse implement first? 1. Initiate an IV with normal saline. 2. Prepare to intubate the client. 3. Administer oxygen at 100%. 4. Ask the client about an iodine allergy.
"1. This intervention should be implemented, but it is not the first action. 2. This does address oxygenation but will take time to accomplish, so this intervention is not the first action. *3. The client is cyanotic with dyspnea and wheezing. The nurse should administer oxygen first. 4. The client may be allergic to iodine, a component of many shellfish, but the first need of the client is oxygenation. TEST-TAKING HINT: The test taker must apply some decision-making standard to determining what to do first. Maslow's hierarchy of needs ranks oxygen as first. Of the two (2) options addressing oxygen, option ""3"" immediately attempts to provide oxygen to the client."
"The client in the HCP's office has a red, raised rash covering the forearms, neck, and face and is experiencing extreme itching which is diagnosed as an allergic reaction to poison ivy. Which discharge instructions should the nurse teach? 1. Tell the client never to scratch the rash. 2. Instruct the client in administering IM Benadryl. 3. Explain how to take a steroid dose pack. 4. Have the client wear shirts with long sleeves and high necks."
"1. This is an unrealistic expectation for a client diagnosed with poison ivy. The pruritus is intense. 2. The client should be instructed on how to use the EpiPen, not IM Benadryl. *3. Clients with poison ivy are frequently prescribed a steroid dose pack. The dose pack has the steroid provided in descending doses to help prevent adrenal insufficiency. 4. This may cause the client to be warm, which increases the likelihood of itching. TEST-TAKING HINT: Option ""1"" has the word ""never,"" which is an absolute word and can be eliminated on this basis. Very few conditions require the nurse to teach the client to take intramuscular (IM) injections; therefore, option ""2"" could be eliminated as a possible answer."
"A nurse is reviewing the chart of a newborn treated for hemolytic disease. Which statement shows the nurse's understanding of the cause of the disease? A. ""Neutrophils attempt to phagocytize the RBCs."" B. ""antibodies bound with an antigen activate the cascade destroying the RBCs."" C. ""Complement activation causes the release of inflammatory chemical mediators resulting in RBC destruction."" D. ""Endogenous antigens stimulate a type II reaction resulting in lysis of the RBC."""
"B. ""Antibodies bound with an antigen activate a cascade destroying the RBCs."""
"Your patient is having a sudden and severe anaphylactic reaction to a medication. You immediately stop the medication and call a rapid response. The patient's blood pressure is 80/52, heart rate 120, and oxygen saturation 87%. Audible wheezing is noted along with facial redness and swelling. As the nurse you know that the first initial treatment for this patient's condition is?A. IV Diphenhydramine B. IV Normal Saline Bolus C. IM Epinephrine D. Nebulized Albuterol"
"C. IM Epinephrine IM or subq Epinephrine is the first-line treatment for anaphylaxis. Epinephrine will cause vasoconstriction (this will increase the blood pressure and decrease swelling) and bronchodilation (this will dilate the airways). This patient's cardiovascular and respiratory system is compromised. Therefore, epinephrine will provide fast relief with anaphylaxis."
Which nursing interventions address the immediate priority of care for a client experiencing a severe hypersensitivity reaction? (select all that apply) A. Assess respiratory status continuously B. Administer subcutaneous epinephrine as prescribed C. Monitor urine output D. Teach the client when and how to use an anaphylactic kit E. Administer oxygen via nasal cannula at the prescribed rate
A. Assess respiratory status continuously B. Administer subcutaneous epinephrine as prescribed E. Administer oxygen via nasal cannula at the prescribed rate
What is the MOST important step a nurse can take to prevent anaphylactic shock in a patient?* A. Assessing, documenting, and avoiding all the patient allergies B. Administering Epinephrine C. Administering Corticosteroids D. Establishing IV access
A. Assessing, documenting, and avoiding all the patient allergies
When planning care for a client admitted with a hypersensitivity reaction, the nurse addresses the potential problem of impaired tissue perfusion. Which intervention will assist in addressing this potential problem? A. Monitoring urine output B. Providing calm reassurance C. Assessing for pain D. Elevating the head of the bed
A. monitoring urine output
The nurse is caring for a client newly diagnosed with seasonal allergic rhinitis. The client is experiencing rhinorrhea, water eyes, and itchy throat. Which prescribed initial treatment does the nurse anticipate? A. Inhaled corticosteroids B. Antihistamine C. Antibiotic D. Oral steroids
B. Antihistamine
For which allergy will the nurse teach the parents that a child with spinal bifida is at increased risk? A. Drug allergy B. Contact dermatitis C. Latex allergy D. Food allergy
C. Latex allergy
The client is experiencing an anaphylactic reaction to bee venom. Which interventions should the nurse implement? List in order of priority. 1. Establish a patent airway. 2. Administer epinephrine, an adrenergic agonist, IVP. 3. Start an IV with 0.9% saline. 4. Teach the client to carry an EpiPen when outside. 5. Administer diphenhydramine (Benadryl), an antihistamine, IVP.
In order of priority: 1, 3, 2, 5, 4. 1. Airway is always the first priority for any process in which the airway might be compromised. 3. The nurse should start an IV so medications can be administered to treat the anaphylactic reaction. 2. Epinephrine is the drug of choice for the treatment of anaphylaxis. The medication is administered every 10 to 15 minutes until the reaction has subsided. Epinephrine is given for its vasoconstrictive action. 5. Benadryl, an antihistamine, is given to block histamine release, reducing capillary permeability. 4. Teaching is important to prevent or treat further reactions, but this will be done after the crisis is over.
Which hypersensitivity reaction releases enzymes that increase tissue damage? A. Type III B. Type IV C. Type I D. Type II
Type III
"A 25-year-old female is admitted to the ER in anaphylactic shock due to a bee sting. According to the patient's mother, the patient is severely allergic to bees and was recently stung by one. This type of anaphylactic reaction is known as a?* A. Type I Hypersensivity Reaction B. Type II Hypersensivity Reaction C. Type III Hypersensivity Reaction D. Type IV Hypersensivity Reaction"
A. Type I Hypersensivity Reaction Type I Hypersensitivity Reactions are immediate and cause anaphylaxis. It occurs when an antigen (the allergen....in this case bee venom) attaches to immunoglobulin E (IgE) antibodies. These antibodies are created due to this allergen and attach to the mast cells and basophils. This leads to a system-wide release of inflammatory mediators (histamine and other inflammatory substances). It is important to note a patient must be sensitized (meaning the immune system has seen the allergen before and produced IgE antibodies in response to the allergen). When the person comes into contact with the foreign substance AGAIN (at a later time) the allergen will attach to that previously created IgE antibody on the mast cell. This will lead to a massive release of histamine and other inflammatory substances that will cause anaphylaxis and lead to anaphylactic shock.
The nurse is caring for a client with a history of anaphylaxis related to a known latex allergy. Which is a priority goal when planning a nursing intervention for the client? A. the client will avoid the known allergen B. The client will teach family members about the life-threatening condition C. The client will verbalize an understanding of the goal D. The client will avoid the foods linked to the latex allergy.
A. the client will avoid the known allergen
to determine the causes of hypersensitivity reaction, a prick test may be used. Which statement is the most accurate to describe this procedure and results? (select all that apply) A. The client must avoid contact with the allergen for 48 hours after the skin test. B. A positive response may include pruritus, erythema, and development of a wheal. C. The allergen is diluted only if a severe systemic reaction is anticipated. D. A positive response can be determined within 15-20 minutes. E. The dil
B. A positive response may include pruritus, erythema, and development of a wheal. D. A positive response can be determined within 15-20 minutes
"Your patient is started on an IV antibiotic to treat a severe infection. During infusion, the patient uses the call light to notify you that she feels a tight sensation in her throat and it's making it hard to breathe. You immediately arrive to the room and assess the patient. While auscultating the lungs you note wheezing. You also notice that the patient is starting to scratch the face and arms, and on closer inspection of the face you note redness and swelling that extends down to the neck a
B. Call a rapid response C. Place the patient on oxygen D. Prepare for the administration of Epinephrine Option A is wrong because the nurse should STOP the infusion, not slow it down because this could be the reason for the anaphylactic reaction. The nurse would want to call a rapid response, place the patient on oxygen, and prepare for the administration of Epinephrine. This drug is the first-line treatment for anaphylactic shock. It will increase the blood pressure, decrease swelling, and dilate the airway.
The nurse is teaching a group of clients with allergies to foods and a history of asthma about the risk factors for the development of anaphylaxis. The nurse identifies which age group as having the highest risk for the development and severity of anaphylaxis? A. Adolescent B. Older adult C. Adult D. Child
B. Older adult
A client is noted to have a type I (IgE-mediated) hypersensitivity reaction with a systemic response. Which clinical manifestation should the nurse anticipate? (Select all that apply) A. Allergic rhinitis B. Stridor C. Wheezing D. Urticaria E. Hypotension
B. Stridor C. Wheezing D. Urticaria E. Hypotension
"What is the BEST position for a patient in anaphylactic shock?* A. Lateral recumbent B. Supine with legs elevated C. High Fowler's D. Semi-Fowler's"
B. Supine with legs elevated This position will increase venous return to the heart, which will help increase cardiac output and blood pressure.
"You're assessing a patient's knowledge on how to use their EpiPen in case of an anaphylactic reaction. You're using an EpiPen trainer device to teach the patient. What demonstrated by the patient shows the patient knows how to administer the medication? Select all that apply:* A. The patient injects the medication in the subq tissue of the abdomen. B. The patient massages the site after injection. C. The patient administers the injection through the clothes. D. The patient aspirates before inje
B. The patient massages the site after injection. C. The patient administers the injection through the clothes. EpiPen is an auto-injector that is administered in the middle of outer thigh. It is not given in the abdomen. The patient should massage the site for 10 seconds after administration to increase absorption. It can be administered through clothes, if needed. Aspiration is not required for administration of this medication.
During anaphylactic shock the mast cells and basophils release large amounts of histamine. What effects does histamine have on the body during anaphylactic shock? Select all that apply:* A. Decreases capillary permeability B. Vasodilation of vessels C. Decreases heart rate D. Shifts intravascular fluid to interstitial space E. Constricts the airways F. Stimulates contraction of GI smooth muscles G. Inhibits the production of gastric secretions H. Itching
B. Vasodilation of vessels D. Shifts intravascular fluid to interstitial space E. Constricts the airways F. Stimulates contraction of GI smooth muscles H. Itching Histamine: INCREASES capillary permeability (not decreases) by shifting the intravascular fluid to the interstitial space...this causes swelling and lowers blood pressure, vasodilates vessels...this lower blood pressure and causes red skin, increases heart rate (not decreases), constricts the airway...this causes difficulty breathing and wheezes, stimulates contraction of GI smooth muscles and stimulates (not inhibits) the production of gastric secretions...this leads to vomiting, nausea, and pain, and there is also itching.
"Which is the nurse's PRIORITY action when managing a client experiencing a type I hypersensitivity? A. Management of arthralgia B. Airway management C. Stopping the blood transfusion D. Decreasing a fever"
B. airway management
A client presents to the clinic with erythema and vesicles on the trunk and bilateral upper and lower extremities. Which type of skin testing should the nurse anticipate being prescribed for the client to determine the cause of hypersensitivity reaction? A. Food allergy test B. Intradermal test C. Epicutaneous test D. Patch test
C. Epicutaneous Test
A client is starting treatment for a hypersensitivity reaction. Which pharmacologic therapy should the nurse anticipate will be initiated to develop IgG antibodies to the allergen? A. Nonsteroidal anti-inflammatory medications B. Corticosteroids C. Immunotherapy D. Antihistamines
C. Immunotherapy
A patient is in anaphylactic shock. The patient has a severe allergy to peanuts and mistakenly consumed an eggroll containing peanut ingredients during his lunch break. The patient is given Epinephrine intramuscularly. As the nurse, you know this medication will have what effect on the body?* A. It will prevent a recurrent attack. B. It will cause vasoconstriction and decrease the blood pressure. C. It will help dilate the airways. D. It will help block the effects of histamine in the body.
C. It will help dilate the airways. Epinephrine acts as a vasopressor and will actually dilate the airway. Epinephrine performs vasoconstriction which will INCREASE the blood pressure. It does not prevent a recurrent attack (corticosteroids may help with this), and it does not block the effects of histamine (antihistamine helps with this).
A patient is having an anaphylactic reaction to an IV medication. What is the FIRST action the nurse should take? A. Administer Epinephrine B. Call a Rapid Response C. Stop the medication D. Administer a breathing treatment
C. Stop the medication The FIRST step the nurse should take is to immediately remove the allergen. This would be stopping the medication, and then call a rapid response. The nurse should maintain the airway and start CPR (if needed) until help arrives.
How are the systemic type I IgE-mediated responses initiated? A. With contact of the allergen and IgE in the conjunctival tissues. B. by contact of the allergen with IgE in the bronchial tree C. the allergen makes contact with the IgE in the circulatory system D. Allergens are absorbed in the GI mucosa
D. Allergens are absorbed in the GI mucosa
The nurse is providing teaching for a client on dietary intake and anaphylaxis. Which food should the nurse identify that trigger anaphylaxis in a sensitized individual (Select all that apply) A. Fish B. Coconut oil C. Milk D. Chocolate E. Grains
D. Chocolate E. Grains
Which referral should the nurse implement for a client with severe multiple allergies? 1. Registered dietitian. 2. Occupational therapist. 3. Recreational therapist. 4. Social worker.
"*1. A dietitian could help the client with any necessary dietary changes for food allergies and with ways to continue to meet nutritional needs. 2. An occupational therapist addresses the client's ability to perform activities of daily living. 3. A recreational therapist works in a psychiatric setting or rehabilitation setting and assists with the client's therapeutic recreational activities. 4. A social worker addresses the client's financial needs."
The client diagnosed with a bee sting allergy is being discharged from the emergency department. Which priority discharge instruction should be taught to the client? 1. Demonstrate how to use an EpiPen, an adrenergic agonist. 2. Teach the client to never go outdoors in the spring and summer. 3. Have the client buy diphenhydramine over the counter to use when stung. 4. Discuss wearing a Medic Alert bracelet when going outside.
"*1. Clients who are allergic to bee sting venom should be taught to keep an EpiPen with them at all times and how to use the device. This could save their lives. 2. It is unrealistic to think the client will never go outdoors, but the client should be taught to avoid exposure to bees whenever possible. 3. Over-the-counter diphenhydramine (Benadryl) is a histamine-1 blocker, but it is oral and not useful in this situation. 4. The client should wear a Medic Alert bracelet, but it is not priority over ensuring the client knows how to treat a bee sting. Wearing the bracelet does not ensure correct treatment of the bee sting. TEST-TAKING HINT: Answer option ""2"" is an absolute and should be eliminated as a possible correct answer."
"The client in the emergency department begins to experience a severe anaphylactic reaction after an initial dose of IV penicillin, an antibiotic. Which interventions should the nurse implement? Select all that apply. 1. Prepare to administer Solu-Medrol, a glucocorticoid, IV. 2. Request and obtain a STAT chest x-ray. 3. Initiate the Rapid Response Team. 4. Administer epinephrine, an adrenergic blocker, SQ then IV continuous. 5. Assess for the client's pulse and respirations."
"*1. Steroid medications decrease inflammation and therefore are one of the treatments for anaphylaxis. 2. A STAT chest x-ray is not indicated at this time. *3. The Rapid Response Team should be called because this client will be in respiratory and cardiac arrest very shortly. *4. Because of its ability to activate a combination of alpha and beta receptors, epinephrine is the treatment of choice for anaphylactic shock. *5. The first step in initiating cardiopulmonary resuscitation is to assess for a pulse and respirations. TEST-TAKING HINT: This is an alternative type-question. If the test taker did not read the sentence ""Select all that apply,"" the fact there are five (5), not four (4), options should alert the test taker to go back and read the stem more closely. Each option must be decided on for itself. The test taker cannot eliminate one option based on the fact another option is correct."
The nurse is developing a care plan for a client diagnosed with allergic rhinitis. Which independent problem has priority? 1. Ineffective breathing pattern. 2. Knowledge deficit. 3. Anaphylaxis. 4. Ineffective coping.
"*1. This can be an independent or collaborative nursing problem. It is an airway problem and has priority. 2. Knowledge deficit is not a priority over the client with breathing problems. 3. Anaphylaxis is a collaborative problem. The nurse will need to start IVs, administer medications, and possibly place the client on a ventilator if the client is to survive. 4. Ineffective coping is a psychosocial problem; it does not have priority over breathing. TEST-TAKING HINT: The test taker must apply some problem-solving/decisionmaking standard. In this case Maslow's hierarchy of needs is a good option. Airway has priority."
"1. The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instructions? 1. ""I should take hot baths because they are relaxing."" 2. ""I should sit whenever possible to conserve my energy."" 3. ""I should avoid long periods of rest because it causes joint stiffness."" 4. ""I should do some exercises, such as walking, when I am not fatigued."""
"1. ""I should take hot baths because they are relaxing."" Rationale: To help reduce fatigue in the client with systemic lupus erythematosus, the nurse should instruct the client to sit whenever possible, avoid hot baths (because they exacerbate fatigue), schedule moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed to avoid long periods of rest because it promotes joint stiffness."
The client diagnosed with an anaphylactic reaction is admitted to the emergency room. Which assessment data indicate the client is not responding to the treatment? 1. The client has a urinary output of 120 mL in two (2) hours. 2. The client has an AP of 110 and a BP of 90/60. 3. The client has clear breath sounds and an RR of 26. 4. The client has hyperactive bowel sounds.
"1. A urinary output of greater than 30 mL/hr is within normal limits and indicates the client is responding to treatment. *2. These vital signs indicate shock, which is a medical emergency and requires immediate intervention. 3. Clear breath sounds indicate response to treatment, and although the RR is increased, this could be the result of anxiety or fear. 4. The client's bowel sounds are not significant data to determine the client's response to treatment."
The nurse in the holding area of the operating room is assessing the client prior to surgery. Which information warrants immediate intervention by the nurse? 1. The client is able to mark the correct site for the surgery. 2. The client can only tell the nurse about the surgery in lay terms. 3. The client is allergic to iodine and does not have an allergy bracelet. 4. The client has signed a consent form for surgery and anesthesia.
"1. By the Joint Commission standards, clients must mark any surgical site to make sure the operation is not done on the incorrect site, such as the right arm instead of the left arm. 2. The client should understand the surgery in his or her own terms. *3. Iodine is the basic ingredient in Betadine (povidone-iodine), which is a common skin prep used for surgeries. Therefore, the nurse should notify the surgeon if the client has an allergy to iodine. 4. The client should have a signed consent for the surgery and the anesthesia prior to surgery. TEST-TAKING HINT: The options involve basic concepts for surgical preparation, and allergies must be identified on the client as well as in the client's chart."
Which is the highest priority nursing intervention for the client who is having an anaphylactic reaction? 1. Administer parenteral epinephrine, an adrenergic agonist. 2. Prepare for immediate endotracheal intubation. 3. Provide a calm assurance when caring for the client. 4. Establish and maintain a patent airway.
"1. Epinephrine is the drug of choice for an anaphylactic reaction. It is a potent vasoconstrictor and bronchodilator counteracting the effects of histamine, but this is not the priority intervention. 2. This is an important intervention, but it is not the priority intervention. 3. Decreasing the client's anxiety is important, but it is not the priority intervention. *4. Establishing a patent airway is priority because facial angioedema, bronchospasm, and laryngeal edema occur with an anaphylactic reaction. Inserting a nasopharyngeal or oropharyngeal airway maintains a patent airway."
The nurse in the emergency department is allergic to latex. Which intervention should the nurse implement regarding the use of nonsterile gloves? 1. Use only sterile, nonlatex gloves for any procedure requiring gloves. 2. Do not use gloves when starting an IV or performing a procedure. 3. Keep a pair of nonsterile, nonlatex gloves in the pocket of the uniform. 4. Wear white cotton gloves at all times to protect the hands.
"1. The nurse should use nonlatex gloves because of the latex allergy, but the gloves do not have to be sterile. 2. The nurse must use gloves during procedures and starting an IV. Not using gloves is a violation of Occupational Safety and Health Administration standards and places the nurse at risk for developing illnesses. *3. The nurse should be prepared to care for a client at all times and should not place himself or herself at risk because the facility does not keep nonlatex gloves available in the rooms. The nurse should carry the needed equipment (nonlatex gloves) with him or her. 4. White cotton gloves are made of cloth and do not provide the barrier against wet substances. TEST-TAKING HINT: The test taker must be aware of adjectives such as ""sterile"" in option ""1."" Basic concepts such as Standard Precautions should cause the test taker to eliminate option ""2."" Option ""4"" has the word ""all"" in it and could be eliminated as an answer because this is an absolute."