Allergy, Anaphylaxis: Q & A

Which nursing intervention is the MOST important for the nurse to perform before administering any drug or therapeutic agent to an adult patient? a. Ask the patient about allergies to drugs or other substances b. Check the medication administration record for allergic response to drugs c. Make sure that emergency medications are readily available d. Be aware of types of drugs that are likely to cause allergic reactions

a. Ask the patient about allergies to drugs or other substances

For a patient who is having an anaphylactic reaction, which common symptoms will manifest ALMOST IMMEDIATELY after being exposed to an allergen? Select all that apply. a. Erythema of the eyes and lips b. Apprehension c. Urticaria d. Chills e. Confusion

a. Erythema of the eyes and lips b. Apprehension c. Urticaria

The nurse is preparing a teaching plan for the patient and family on how to use and care for an automatic epinephrine injector. Which essential points must the nurse include? Select all that apply. a. Keep the device with you at all times b. You can inject the drug right through your pants c. Inject yourself when you get short of breath d. Protect the device from light and avoid temperature extremes e. Keep the safety cap in place until you are ready to use the device

a. Keep the device with you at all times b. You can inject the drug right through your pants d. Protect the device from light and avoid temperature extremes e. Keep the safety cap in place until you are ready to use the device

An older resident living in a long term care facility asks for help to go to the bathroom more frequently than usual. The nurse suspects a urinary tract infection. What changes in the immune system of an older adult should the nurse keep in mind? Select all that apply. a. Older adults are more at risk for bacterial and fungal infections in the genitourinary tract b. Older adults may have an infection but not show expected changes in white blood cell counts c. Older adults may not have a fever during inflammatory or infectious episodes d. Urinalysis results for older patients are more likely to show false negative results e. Neutrophil counts may be normal, but activity is reduced, increasing the risk for infection

a. Older adults are more at risk for bacterial and fungal infections in the genitourinary tract b. Older adults may have an infection but not show expected changes in white blood cell counts c. Older adults may not have a fever during inflammatory or infectious episodes e. Neutrophil counts may be normal, but activity is reduced, increasing the risk for infection

Which patients have factors that may affect the function of the immune system? Select all that apply. a. Patient has been on a severely limited diet for several weeks to quickly lose weight b. Patient is homeless and is continuously seeking shelter for cold weather conditions c. Patient is on multiple medications, including corticosteroids and a nonsteroidal anti-inflammatory d. Patient is 84 yrs old and lives alone in her own house e. Patient has type 2 diabetes mellitus that is well controlled with oral antidiabetic medication

a. Patient has been on a severely limited diet for several weeks to quickly lose weight b. Patient is homeless and is continuously seeking shelter for cold weather conditions c. Patient is on multiple medications, including corticosteroids and a nonsteroidal anti-inflammatory d. Patient is 84 yrs old and lives alone in her own house e. Patient has type 2 diabetes mellitus that is well controlled with oral antidiabetic medication

The actions of leukocytes provide the protection against invading organisms. What are actions of leukocytes? Select all that apply. a. Phagocytic destruction of foreign invaders and unhealthy or abnormal cells b. Lytic destruction of foreign invaders and unhealthy cells c. Stimulate maturational pathway of stem cells d. Production of antibodies directed against invaders e. Production of cytokines that decrease specific leukocyte growth and activity

a. Phagocytic destruction of foreign invaders and unhealthy or abnormal cells b. Lytic destruction of foreign invaders and unhealthy cells d. Production of antibodies directed against invaders

Which allergy management strategy is BEST for a patient who has a history of allergic asthma? a. Practicing avoidance b. Undergoing desensitization c. Taking corticosteroids d. Carrying an automatic epinephrine injector

a. Practicing avoidance

A nurse is working in a summer camp. One of the campers comes to the clinic with several bee stings. Which clinical manifestations would require administration of epinephrine (EpiPen)? Select all that apply. a. Skin that is cold and clammy to the touch b. Skin that is warm and dry to the touch c. Hyperactive and hyperverbal behavior d. Wheezing e. Restlessness and confusion

a. Skin that is cold and clammy to the touch d. Wheezing e. Restlessness and confusion

The nurse is caring for a patient prescribed a new oral antibiotic. Eosinophil and basophil levels are elevated. What is the nurse's BEST interpretation of this lab report? a. The patient may be having an allergic reaction to the antibiotic b. The patient's body is fighting off an infection c. The patient's white blood cells are phagocytizing the invasive organisms d. The patient is at high risk for pneumonia and other respiratory infections

a. The patient may be having an allergic reaction to the antibiotic

A patient is admitted with pneumonia and has developed sepsis. What can the findings from a differential white blood cell count reveal about this patient? a. Whether an infection is bacterial or viral b. Whether the patient has active immunity c. The tissue type from the human leukocyte antigen d. The type of antibody response occurring

a. Whether an infection is bacterial or viral

The health care provider writes a prescription for the patient to be immunized with the flu vaccine. Which type of immunity does the nurse provide the patient by injecting this vaccine? a. Natural active immunity b. Artificial active immunity c. Adaptive immunity d. Passive immunity

b. Artificial active immunity

The patient has anaphylaxis. What is the major factor that is MOST LIKELY to result in the patient's death? a. Delay in locating intubation equipment b. Delay in administering epinephrine c. Inappropriately discharging the patient d. Administering the wrong rescue medication

b. Delay in administering epinephrine

The nurse is performing a physical assessment on an adult with no known health problems. Which assessment finding poses the GREATEST potential threat to the patient's immune system? a. Has old scar formation related to an appendectomy b. Has poor oral hygiene and numerous dental caries c. Displays occasional skipped heartbeats during auscultation d. Displays orthostatic hypotension and is mildly dehydrated

b. Has poor oral hygiene and numerous dental caries

For a patient with anaphylaxis, which PRIORITY treatment does the nurse expect to administer? a. Oral diphenhydramine b. Intravenous epinephrine c. Albuterol via high flow nebulizer d. Intravenous corticosteroids

b. Intravenous epinephrine

The nurse is reviewing the patient's laboratory results and sees that there is a left shift (bandemia). Which assessment is the nurse MOST LIKELY to perform? a. Look for signs of bleeding, such as petechiae b. Look for signs of infection and check temperature and pulse c. Check for signs of anemia, such as pallor or tachycardia d. Check for signs and symptoms of inflammatory response

b. Look for signs of infection and check temperature and pulse

A nurse is caring for a patient with seasonal hypersensitivity reactions. What teaching does the nurse include in the patient's plan of care? a. Keep doors and windows open to circulate air b. Maintain a clean, dust-free environment c. Avoid the use of diphenhydramine hydrochloride (Benadryl). d. Stop taking oral corticosteroids once symptoms disappear

b. Maintain a clean, dust-free environment A patient with seasonal hypersensitivity should be educated regarding prevention and comfort measures. The nurse should also include teaching on maintaining a clean, dust-free environment.

In which conditions might the nurse observe inflammation WITHOUT infection? Select all that apply. a. Contact dermatitis b. Joint sprains c. Myocardial infarction d. Blister formation e. Allergic rhinitis

b. joint sprains c. myocardial infarction d. blister formation e. allergic rhinitis a. contact dermatitis

The nurse is caring for a patient with a history of latex allergies. The patient develops audible wheezing, pruritus, urticaria, and signs of angioedema. Which is the priority intervention for this patient? a. Notify the healthcare provider b. Administer prescribed diphenhydramine (Benadryl) by mouth every 4 hours c. Administer prescribed epinephrine 1:1,000 by subcutaneous injection per the healthcare provider's orders. d. Obtain a complete set of vital signs

c. Administer prescribed epinephrine 1:1,000 by subcutaneous injection per the healthcare provider's orders. For mild reactions with wheezing, pruritus, urticaria, and angioedema, a subcutaneous injection of 0.3 to 0.5 mL of 1:1,000 epinephrine is generally sufficient. The nurse should give the epinephrine first because of the clinical manifestations. Epinephrine is the medication of choice to counteract anaphylactic shock by causing blood vessel constriction, raising blood pressure, and improving cardiac output through inotropic and chronotropic activity. It also acts as a beta-2 agonist to promote bronchial smooth muscle relaxation.

The nurse assesses a patient who sustained a scalding burn to the left dorsal surface of the hands and fingers that occurred one day ago. There is redness, swelling, and warmth. The patient has pain, decreased fine motor movements, and limited range of motion. What do these findings indicate? a. Stage II of inflammation b. Serious infection that should be reported c. Cardinal signs of inflammation d. Probable inappropriate first aid treatment

c. Cardinal signs of inflammation

Which type of white blood cell does the body produce most? a. Macrophages b. Eosinophils c. Neutrophils d. Band Neutrophils

c. Neutrophils

Which type of infection is MOST LIKELY to result in a left shift (bandemia) that indicates an increased number of immature neutrophils? a. Viral b. Parasitic c. Fungal d. Bacterial

d. Bacterial

The nurse is caring for a patient who is experiencing anaphylactic shockafter the administration of a medication. Which position is the most appropriate for the nurse to place the patient based on this data? a. Trendelenburg position b. Flat, with legs slightly elevated c. Supine position d. High-Fowler's position

d. High-Fowler's position

A nurse is caring for a patient who is receiving an infusion of intravenous antibiotic at the ambulatory clinic. Which clinical manifestation indicates that the patient is experiencing a type I hypersensitivity reaction? a. Erythema b. Fever c. Joint pain d. Hypotension

d. Hypotension

A patient in anaphylaxis is at risk for respiratory failure. Which assessment findings prompts the nurse to prepare equipment to assist the health care provider to intubate the patient? a. Crackles b. Hypoxemia c. Wheezing d. Stridor

d. Stridor

A patient has a sustained a severe right ankle sprain, and the nurse is explaining the process of inflammation to the patient and family. Which information does the nurse include in this teaching? a. Because inflammation is present, treatment for infection is advised b. The inflammatory response is painful but provides long-term protection c. Inflammation is a specific body defense in response to the ankle injury d. Symptoms of inflammation depend on the intensity and severity of the injury

d. Symptoms of inflammation depend on the intensity and severity of the injury

The nurse is preparing the 9:00 am medication and sees that the patient is due for a morning dose of thalidomide. The nurse has heard of the medication but is not exactly sure why it has been prescribed for this patient. What should the nurse do? a. Give the 9:00 am dose so it is not delayed and look up the drug when there is more time. b. Ask the patient if the medication looks familiar and why it was prescribed c. Call the health care provider and ask for clarification of the order and the purpose of the drug d. Use a drug resource to lookup information and cross check the patient's medical history

d. Use a drug resource to lookup information and cross check the patient's medical history

A nurse is exposed to a viral infection at work. After several days, the nurse fully recovers and returns to work. What is the role of the memory cell in relation to the nurse's viral illness? a. The memory cell reminds the nurse's healthy cells to function after recovery b. If the nurse develops other viral infections, the memory cell seeks out an antigen match c. The memory cell prevents viral shedding from the nurse to patients who are immunocompromised d. When the nurse is re-exposed to the same antigen, the memory cell will produce antibodies.

d. When the nurse is re-exposed to the same antigen, the memory cell will produce antibodies.

Which findings are the MOST LIKELY to manifest in a patient who is experiencing the release of histamine and kinins by basophils? a. Fever & tachycardia b. foul odor & pus c. shortness of breath d. swelling & edema

d. swelling & edema

The nurse is caring for a patient and suspects anaphylaxis. What PRIORITY action does the nurse perform? a. Place the patient on a cardiac monitor and observe for arrhythmias b. Insert a large bore intravenous IV line with normal saline c. Ask the patient to describe previous responses to various types of allergens d. Apply oxygen using a high flow, non rebreather mask at 90-100%

Apply oxygen using a high flow, non rebreather mask at 90-100%

Which type I hypersensitivity reaction requires IMMEDIATE INTERVENTION by the nurse? a. Rhinosinusitis b. Bronchoconstriction c. Urticaria d. Pruritus

Bronchoconstriction

Which clinical examples are type I immediate hypersensitivities? Select all that apply a. Goodpasture's syndrome b. Hay fever c. Serum sickness d. Anaphylaxis e. Allergic asthma

Hay fever Anaphylaxis Allergic asthma

The patient has a documented allergy to latex. Which piece of common medical equipment could trigger the patient's latex allergy if special precautions are not taken to ensure a latex-free product? a. Indwelling urinary catheter b. 4X4 gauze sponge c. Blood pressure cuff d. Hospital meal tray

Indwelling urinary catheter

The nurse is taking a history on a patient who is scheduled to undergo diagnostic testing with use of contrast dye. Which patient statement is cause for GREATEST concern? a. My sister is allergic to the dye that they use for x-ray procedures b. I have a lot of seasonal allergies, and they make me pretty miserable c. My doctor thinks I might be at risk for diabetes and high blood pressure d. Last year I had a procedure and my face got so swollen I could not see

Last year I had a procedure and my face got so swollen I could not see

The nurse has just received handoff reports on several patients who are being treated for hypersensitivity or autoimmune responses. Which patient is the nurse most likely to check on first? a. Patient who was treated for angioedema with epinephrine and oxygen b. Patient who has serum sickness and received a dose of oral diphenhydramine c. Patient who had hemolytic transfusion reaction and infusion was discontinued d. Patient with tissue transplant rejection awaiting transplant surgeon consult

Patient who was treated for angioedema with epinephrine and oxygen

Which clinical condition BEST represents a type IV stimulated hypersensitivity? a. Poison ivy b. Graves' disease c. Myasthenia gravis d. Vasculitis

Poison ivy

The nursing instructor is quizzing a nursing student about the pharmacologic action of a decongestant drug that is prescribed for the patient. What is the BEST response to the instructor's query? a. This drug will prevent vasodilation and decrease secretions b. This drug causes vasoconstriction and reduces the swelling c. This drug will decrease allergens and allergic response d. This drug will desensitize any allergic reactions

This drug causes vasoconstriction and reduces the swelling