Quiz 4 CH 19

2. Allergic rhinitis

The nurse is caring for a client exhibiting symptoms of nasal itching, watery rhinorrhea, itchy red eyes, and sneezing. The nurse suspects this client has which of the following diagnoses? 1. Atopic dermatitis 2. Allergic rhinitis 3. Urticaria 4. Serum sickness

4. Turn off the antibiotic.

A patient is being given penicillin via intravenous (IV) infusion and develops an anaphylactic reaction. Which of the following should be the nurse's first action? 1. Call the doctor. 2. Call for help. 3. Maintain the antibiotic. 4. Turn off the antibiotic.

3. Stay with the patient. 4. Turn off the intravenous infusion. 5. Call for assistance. 6. Monitor vital signs

A patient is receiving cefuroxime (Zinacef) intravenously. Fifteen minutes after the cefuroxime is started, the patient reports an uneasy feeling as well as feeling very warm. Which actions would the nurse take now? Select all that apply. 1. Offer the patient ice water. 2. Discontinue the angiocath. 3. Stay with the patient. 4. Turn off the intravenous infusion. 5. Call for assistance. 6. Monitor vital signs

1. Wear medical alert identification.

A patient is stabilized after having an allergic reaction. Which preventive instructions should the nurse reinforce with the patient? 1. Wear medical alert identification. 2. Stay indoor as much as possible. 3. Wear insect repellent when outdoors. 4. Take corticosteroids before going outdoor

1. Administer oxygen. 3. Establish a patent IV access. 6. Position the patient in a semi- to high-Fowler's position.

A patient is suspected as experiencing anaphylaxis. Which actions should the nurse anticipate being needed for this patient? Select all that apply. 1. Administer oxygen. 2. Administer antibiotics. 3. Establish a patent IV access. 4. Administer pain-relieving medications. 5. Prepare the patient for magnetic resonance imaging (MRI). 6. Position the patient in a semi- to high-Fowler's position.

b. Direct Coombs test

A patient is suspected as having a blood transfusion reaction. Which laboratory test should the nurse expect to be done to confirm this diagnosis? a. Skin testing b. Direct Coombs test c. White blood cell count d. C-reactive protein level

a. Cotton allows air movement. b. White cotton has no dye in the material. e. Scratching is less during sleep when the area is covered.

The nurse applies clean white cotton socks over the hands of a patient with contact dermatitis. What should the nurse explain to the patient about the purposes of this intervention? (Select all that apply.) a. Cotton allows air movement. b. White cotton has no dye in the material. c. White cotton prevents the wounds from spreading. d. The cotton will absorb the drainage from the wounds. e. Scratching is less during sleep when the area is covered.

2. Wearing a mask when mowing the lawn

The nurse contributed to the teaching plan for a patient with a history of allergies to pollen. Which patient action indicates an understanding of how to control this disease? 1. Gardening outdoors on dry, windy days 2. Wearing a mask when mowing the lawn 3. Driving the car with the windows open during high pollen counts 4. Taking frequent walks outside in spring when the weather is warm

1. Pallor 4. Weakness 5. Glossitis 6. Peripheral neuropathy

The nurse is assessing a patient with pernicious anemia. Which clinical manifestations can the nurse expect to document? (Select all that apply.) 1. Pallor 2. Wheals on the skin 3. Butterfly rash 4. Weakness 5. Glossitis 6. Peripheral neuropathy

d. A patient receiving a blood transfusion who is reporting chills and low back pain

The nurse is caring for a group of patients. Which patient should the nurse see first? a. A patient with Hashimoto thyroiditis who reports diarrhea and weight loss b. A patient with allergic rhinitis with copious amounts of clear nasal drainage c. A patient with SLE with a butterfly rash d. A patient receiving a blood transfusion who is reporting chills and low back pain

2. Covering heating ducts with filters

The nurse is contributing to the teaching plan for a patient who is allergic to dust. Which environmental modification should the nurse recommend be included in the teaching plan to help control symptoms? 1. Installing a hot air heater 2. Covering heating ducts with filters 3. Installing wall-to-wall carpeting 4. Using heavy draperies on sunny windows

Admin epinephrine IV

The nurse working in a clinic when a patient presents with shortness of breath, wheezing, and hives. The nurse should plan to implement which order first?

2. Notify the health care provider (HCP) 3. Stop the blood transfusion immediately 4. Monitor symptoms and vital signs 5. Inform the blood bank

A client receiving a blood transfusion experiences a sudden onset of chest pain, tachycardia, tachypnea, dyspnea, and urticaria. The nurse concludes this client is experiencing a hemolytic transfusion reaction. Which of the following actions will the nurse take? Select all that apply. 1. Double-check the patient's blood type in the medical record 2. Notify the health care provider (HCP) 3. Stop the blood transfusion immediately 4. Monitor symptoms and vital signs 5. Inform the blood bank

3. "Viral illnesses and exposure to various chemicals and environmental substances can alter the immune system and its response to previously benign stimuli."

A patient asks the nurse how an allergy can develop to a medication that has been taken before without problems. Which of the following is the most appropriate for the nurse to respond? 1. "It probably is due to your age, because as we age, the body becomes more sensitive to environmental stimuli, which leads to hypersensitivities." 2. "What have you eaten in the last 24 hours? Most medications are altered by food, thereby producing different effects in the body." 3. "Viral illnesses and exposure to various chemicals and environmental substances can alter the immune system and its response to previously benign stimuli." 4. "Patients who have autoimmune disorders such as lupus or arthritis tend to develop sensitivities to common medications."

3. "When the itching is bad, I soak the area in warm water."

The nurse has taught the patient with atopic dermatitis ways to treat and prevent episodes of itching and dryness. What statement by the patient indicates that additional teaching is necessary? 1. "I wear cotton clothing in the summer." 2. "I use a humidifier in my bedroom in the winter." 3. "When the itching is bad, I soak the area in warm water." 4. "I look for any signs of redness, scaling, or breaks in the skin."

d. Poison ivy e. Poison oak

The nurse is assisting in an educational seminar on common allergens. What should the nurse include as the most common irritant causing contact dermatitis? (Select all that apply.) a. Bleach b. Rubber c. Fire ants d. Poison ivy e. Poison oak

a. Hives

The nurse is caring for a patient who is stung by a wasp. Which manifestation should the nurse expect if an allergic reaction develops? a. Hives b. Retinal hemorrhage c. Jugular vein distention d. Pallor around the sting sites

b. Topic drying agent c. Oral antihistamines d. Topical corticosteroid e. Topical immunomodulators

The nurse is experiencing severe skin blisters after wearing latex gloves at work. Which treatment should the nurse expect to be prescribed by the health care provider for these skin lesions? (Select all that apply.) a. Oral antibiotics b. Topic drying agent c. Oral antihistamines d. Topical corticosteroid e. Topical immunomodulators

1. Stop the transfusion. 2. Transfuse normal saline as ordered. 3. Notify the health-care provider. 4. Return the unused blood and tubing to the blood bank.

The nurse is monitoring a client who is receiving a blood transfusion. The client suddenly reports chills, low back pain, tachycardia, and dyspnea. Aside from remaining with the client, place the nursing actions in order from first to last.

2. "Are you allergic to any medication?"

The nurse is preparing to administer levofloxacin (Levaquin) to a patient with pneumonia. Which is most important for the nurse to ask prior to administering the medication? 1. "Have you experienced nausea or vomiting from antibiotics?" 2. "Are you allergic to any medication?" 3. "Do you know why you are receiving this medication?" 4. "Do you have an allergy to latex?"

A. Stop the blood infusion. C. Obtain vital signs and assess patient. B. Notify the physician stat. E. Prepare a new 0.9% normal saline infusion. D. Start the new 0.9% normal saline infusion.

1. A patient is receiving a blood transfusion of packed RBCs. Ten minutes after the infusion begins, the patient reports low back pain and a headache. Place the actions in order (1-5) of importance of performance. A. Stop the blood infusion. B. Notify the physician stat. C. Obtain vital signs and assess patient. D. Start the new 0.9% normal saline infusion. E. Prepare a new 0.9% normal saline infusion.

1. Administer oxygen as prescribed. 2 Place an endotracheal (ET) intubation kit at the bedside. 4. Place the client on a cardiac monitor. 5. Obtain the prescribed intravenous (IV) access.

A client presents to the emergency department with stridor, wheezing, dyspnea, and facial edema. The nurse concludes this client is experiencing an anaphylactic reaction. Which interventions will the nurse implement? Select all that apply. 1. Administer oxygen as prescribed. 2 Place an endotracheal (ET) intubation kit at the bedside. 3. Administer the prescribed antibiotic. 4. Place the client on a cardiac monitor. 5. Obtain the prescribed intravenous (IV) access.

c. 15

A patient is being started on a blood transfusion. For how many minutes should the nurse stay with the patient during this transfusion? a. 5 b. 10 c. 15 d. 20

1. Type I

A patient is diagnosed with a hypersensitivity reaction mediated by immunoglobulin E (IgE) antibodies. For which type of hypersensitivity reaction should the nurse plan care for this patient? 1. Type I 2. Type II 3. Type III 4. Type IV

a. Type I

A patient is diagnosed with urticaria. For which type of hypersensitivity reaction should the nurse plan care for this patient? a. Type I b. Type II c. Type III d. Type IV

c. Using relaxation techniques

A patient is experiencing an episode of urticaria. Which intervention should the nurse recommend to include in the teaching plan to assist the patient in controlling the symptoms of urticaria? a. Avoiding tub baths b. Taking one aspirin daily c. Using relaxation techniques d. Drinking decaffeinated coffee

1. Stop the blood infusion.

A patient is receiving a transfusion of packed RBCs. Ten minutes after the infusion begins, the patient reports low back pain and a headache. Which action should the nurse take first? 1. Stop the blood infusion. 2. Notify the physician STAT. 3. Start a normal saline infusion. 4. Check vital signs.

3. Verify blood type of the patient and donor.

A patient is to receive a transfusion of packed RBCs. Before administering the transfusion, which action should the nurse take? 1. Verify the patient's kidney function. 2. Verify the patient's hematocrit level. 3. Verify blood type of the patient and donor. 4. Verify the patient's admitting medical diagnosis

1. Stop the transfusion.

A patient receiving a blood transfusion suddenly feels pain in the chest, experiences nausea, and appears anxious. The nurse notes tachypnea and tachycardia and a blood pressure of 100/65 mm Hg. What should the nurse do first? 1. Stop the transfusion. 2. Report to the registered nurse (RN) and physician. 3. Prepare a new intravenous (IV) infusion set for normal saline. 4. Explain to the patient that these symptoms may occur with a blood transfusion.

3. Stay with the patient. 4. Turn off the IVPB (IV piggyback). 5. Call for assistance. 6. Monitor vital signs.

A patient who has an allergy to penicillin is receiving cefazolin (Ancef) intravenously. Fifteen minutes after the cefazolin is started, the patient reports an uneasy feeling, as well as feeling very warm. Which actions would the nurse take now? Select all that apply. 1. Offer the patient ice water. 2. Discontinue the IV. 3. Stay with the patient. 4. Turn off the IVPB (IV piggyback). 5. Call for assistance. 6. Monitor vital signs.

O type blood

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

1. Physical therapy daily 3. Tylenol #3 every 4 hours prn for pain 4. Administering Remicade as prescribed 5. Activity as tolerated; up with assistance

The nurse is assisting in the care of a patient with ankylosing spondylitis. What should the nurse expect to find in the patient's collaborative plan of care? (Select all that apply.) 1. Physical therapy daily 2. Sitz baths three times daily 3. Tylenol #3 every 4 hours prn for pain 4. Administering Remicade as prescribed 5. Activity as tolerated; up with assistance

1. Raised, pruritic, nontender, erythematous wheals on the skin

The nurse is caring for a client admitted with urticaria. Which clinical manifestations will the nurse expect to see during assessment? 1. Raised, pruritic, nontender, erythematous wheals on the skin 2. Pruritis, edema, and extremely dry skin 3. Sneezing, itching, rhinorrhea, and itchy eyes 4. Fever, malaise, muscle soreness, arthralgia, and splenomegaly

2. The UAP wears powdered latex gloves when bathing the client.

The nurse is caring for a client with a latex allergy. Which of the following requires correction by the nurse? 1.The unlicensed assistive personnel (UAP) places a cart with latex-free supplies outside the client's room. 2. The UAP wears powdered latex gloves when bathing the client. 3. The UAP removes the avocado and banana from the lunch tray. 4. The UAP places a "latex allergy" sign on the client's door.

1. Administration of a prescribed antihistamine. 2. Teach client to avoid environmental stimuli. 3. Administration of corticosteroids as ordered.

The nurse is caring for a client with allergic rhinitis. Which interventions will the nurse anticipate implementing? Select all that apply. 1. Administration of a prescribed antihistamine. 2. Teach client to avoid environmental stimuli. 3. Administration of corticosteroids as ordered. 4. Administration of antibiotics as ordered. 5. Routinely check vital signs every 2 hours.

1. Carry an epinephrine pen at all times.

The nurse is caring for a client with an allergy to bee stings. Which of the following is most important for the nurse to teach the client? 1. Carry an epinephrine pen at all times. 2. Avoid going outdoors in the summer. 3. Take 50 mg of diphenhydramine (Benadryl) 2 hours before going outside. 4. Encourage the client to remove all bee hives from their home.

4. A client receiving a blood transfusion who reports fever, low back pain, and itching

The nurse is caring for a group of clients. Which client will the nurse see first? 1. A client with contact dermatitis who reports redness and itching to both hands 2. A client receiving the fifth dose of antibiotic who reports of watery diarrhea 3. A client with ankylosing spondylitis who reports joint pains in early mornings 4. A client receiving a blood transfusion who reports fever, low back pain, and itching

4. A patient stung by an insect experiencing angioedema

The nurse is caring for a group of patients. Which patient should the nurse see first? 1. A patient with serum sickness experiencing fever and malaise 2. A patient with atopic dermatitis with red, weeping lesions 3. A patient with ankylosing spondylitis reporting level 4 back pain 4. A patient stung by an insect experiencing angioedema

c. Administer diphenhydramine (Benadryl) 50 mg IV

The nurse is caring for a patient who develops a hemolytic reaction during a blood transfusion. The nurse should expect to implement which order which order form the HCP first? a. Place patient in a Trendelenburg position b. Call the blood back to send up a different unit of blood c. Administer diphenhydramine (Benadryl) 50 mg IV d. Administer acetaminophen (Tylenol)

2. Report signs of infection immediately.

The nurse is caring for a patient who underwent a liver transplant and is taking cyclosporine (Sandimmune) and azathioprine (Imuran). Which important information should the nurse teach the patient regarding the medication? 1. Take on an empty stomach. 2. Report signs of infection immediately. 3. Monitor for signs of abnormal bleeding. 4. Urine will turn orange.

1. Notify the health care provider (HCP).

The nurse is caring for a patient with SLE. The nurse notes that the patient has foamy, "coke"-colored urine. Which action should the nurse take? 1. Notify the health care provider (HCP). 2. Encourage the patient to increase fluid intake. 3. Prepare the patient for dialysis. 4. Instruct the patient to eat high-protein meals.

b. Subcutaneous epinephrine

The nurse is caring for a patient with a severe allergic reaction. Which medication and route should the nurse anticipate being ordered for this patient? a. Intramuscular morphine b. Subcutaneous epinephrine c. IV diphenhydramine d. Oral diphenhydramine (Benadryl)

c. Diphenhydramine (Benadryl)

The nurse is caring for a patient with a severe allergic reaction. Which medication should the nurse anticipate being administered to control the itching? a. Morphine b. Epinephrine c. Diphenhydramine (Benadryl) d. Hydrocortisone sodium succinate (Solu-Cortef)

1. Antihistamines 2. Avoiding environmental stimuli 3. Immunotherapy 4. Steroids 6. Decongestants

The nurse is caring for a patient with allergic rhinitis. Which of the following interventions should the nurse anticipate will be included in the treatment plan for this patient? Select all that apply. 1. Antihistamines 2. Avoiding environmental stimuli 3. Immunotherapy 4. Steroids 5. Anticholinergics 6. Decongestants

1. Monitor for restlessness.

The nurse is caring for a patient with angioedema. Which nursing action should have the highest priority? 1. Monitor for restlessness. 2. Identify cause of the angioedema. 3. Identify the presence of skin lesions. 4. Teach the patient about immunotherapy.

1. Assist with ambulation

The nurse is caring for a patient with idiopathic autoimmune hemolytic anemia. Which action should the nurse include in the plan of care for this patient? 1. Assist with ambulation 2. Teach good hand hygiene. 3. Avoid intramuscular injections. 4. Obtain manual blood pressures.

2. Vitamin B12

The nurse is caring for a patient with pernicious anemia. Which deficiency is this patient experiencing? 1. Vitamin A 2. Vitamin B12 3. Vitamin C 4. Vitamin D

1. Administer acetaminophen (Tylenol) as ordered.

The nurse is caring for a patient with serum sickness. Which intervention should the nurse implement? 1. Administer acetaminophen (Tylenol) as ordered. 2. Prepare the patient for a blood transfusion. 3. Teach the patient about immunosuppressive drugs. 4. Restrict the patient's fluid intake.

2. Appearance of skin lesions

The nurse is collecting data from a patient with contact dermatitis. Which data is essential for the nurse to obtain? 1. Date of gastric surgery 2. Appearance of skin lesions 3. Weight gain 4. Appetite

1. A patient who receives IV penicillin for an infection

The nurse is contributing to a group of patients care plans. Which patient should the nurse identify as being at risk for developing serum sickness? 1. A patient who receives IV penicillin for an infection 2. A patient who has a transfusion with packed red blood cells (RBCs) 3. A patient who is given cryoprecipitate and factor IX after an abdominal injury 4. A patient given steroids and immunosuppressant therapy after organ transplantation

a. Anaphylaxis b. Angioedema d. Allergic rhinitis

The nurse is contributing to a staff education program about nursing care for hypersensitivity reactions. Which should the nurse include as examples of type I hypersensitivity reactions? (Select all that apply.) a. Anaphylaxis b. Angioedema c. Serum sickness d. Allergic rhinitis e. Contact dermatitis f. Hypogammaglobulinemia

1. Eat a balanced diet. 2. Report "foamy urine" to physician. 6. Use a daily personal schedule to plan activities to reduce fatigue.

The nurse is contributing to the plan of care for a patient with SLE. Which interventions should the nurse recommend for this patient? (Select all that apply.) 1. Eat a balanced diet. 2. Report "foamy urine" to physician. 3. Take cool showers or baths to relieve joint stiffness. 4. Avoid naps and obtain a minimum of 6 hours of sleep. 5. Exercise when pain and inflammation in joints are increased. 6. Use a daily personal schedule to plan activities to reduce fatigue.

1. Eat a soft diet. 2. Increase activity slowly. 6. During low-energy periods, use anti-embolism stockings.

The nurse is contributing to the teaching plan for a patient diagnosed with Hashimoto thyroiditis who has progressed to hypothyroidism with a goiter. Which self-care instructions should the nurse recommend? (Select all that apply.) 1. Eat a soft diet. 2. Increase activity slowly. 3. Eat more foods high in iodine. 4. Keep home at a cool temperature. 5. Eat a high-carbohydrate, high-protein diet. 6. During low-energy periods, use anti-embolism stockings.

1."I should be careful when driving while taking this medication."

The nurse is evaluating if teaching was effective for a client with a prescription of diphenhydramine for itching. Which statement made by the client indicates an understanding? 1."I should be careful when driving while taking this medication." 2. "I can still take my loratadine while taking this medication." 3."I must take this medication with food." 4. "I can drink alcohol in moderation."

a. Keep fingernails short. b. Take baths with an oatmeal solution. c. Use oil-in-water lubricants for skin dryness. f. Use cool washcloths over affected area to ease itching.

The nurse is participating in a teaching plan to address Risk for Impaired Skin Integrity for a patient with contact dermatitis. Which information should the nurse recommend be included in this plan? (Select all that apply.) a. Keep fingernails short. b. Take baths with an oatmeal solution. c. Use oil-in-water lubricants for skin dryness. d. Rub affected area roughly, but do not scratch. e. Avoid washing affected area with brown soap. f. Use cool washcloths over affected area to ease itching.

2. Phenytoin (Dilantin)

The nurse is reviewing orders for a patient with systemic lupus erythematosus (SLE). For which medication should the nurse request clarification? 1. Levothyroxine (Synthroid) 2. Phenytoin (Dilantin) 3. Promethazine (Phenergan) 4. Pantoprazole (Protonix)

"what happens when you take the medication?"

The nurse is taking a medication history for a newly admitted patient. The patient states he is allergic to levofloxacin (Levaquin). Which response by the nurse is most appropriate?

1. "What you are experiencing is a side effect to the medication, not an allergy."

The nurse is taking a medication history of a client who reports an allergy to penicillin. The nurse asks what happens when they take penicillin, and the client states, "My stomach gets upset and I have diarrhea." Which of the following responses by the nurse is best? 1. "What you are experiencing is a side effect to the medication, not an allergy." 2. "You need to carry an EpiPen with you in case this happens while taking the medication." 3. "You should wear a medical alert bracelet listing penicillin allergy." 4. "You should not take cephalosporins because you can have a reaction to drugs from this class too."

2. "I can take my nasal medication any time my allergies bother me."

The nurse is teaching a patient about allergic rhinitis. Which statement indicates a need for further teaching? 1. "I will wear a mask when I mow the yard." 2. "I can take my nasal medication any time my allergies bother me." 3. "I will dust my house every day." 4. "I cannot receive immunotherapy since my allergies are not severe."

3. "I will soak in a lukewarm bath at night."

The nurse is teaching a patient about atopic dermatitis (Eczema). Which statement made by the patient indicates an understanding of the teaching? 1. "I will keep my nails long so I can scratch easier." 2. "I should soak in bleach daily." 3. "I will soak in a lukewarm bath at night." 4. "It is better for me to scratch than to rub the itchy area."

3. "If I get plenty of sunlight, it will help reduce symptoms."

The nurse is teaching a patient with SLE about avoiding triggers. Which statement made by the patient indicates a need for further teaching? 1. "Instead of working in the yard, I got plenty of rest." 2. "I am practicing yoga to help alleviate stress in my life." 3. "If I get plenty of sunlight, it will help reduce symptoms." 4. "I need to check with my doctor before stopping any medication."