ch 14

1. A patient who is receiving an IV antibiotic develops wheezes and dyspnea. In which order should the nurse implement these prescribed actions? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Discontinue the antibiotic infusion. b. Give diphenhydramine (Benadryl) IV. c. Inject epinephrine (Adrenalin) IM or IV. d. Prepare an infusion of dopamine (Intropin). e. Start 100 % oxygen using a nonrebreather mask.

ANS: A, E, C, B, D The nurse should initially discontinue the antibiotic, since it is the likely cause of the allergic reaction. Next, oxygen delivery should be maximized, followed by treatment of bronchoconstriction with epinephrine administered IM or IV. Diphenhydramine will work more slowly than epinephrine, but will help prevent progression of the reaction. Since the patient currently does not have evidence of hypotension, the dopamine infusion can be prepared last.

18. A pregnant patient with a family history of cystic fibrosis (CF) asks for information about genetic testing. The most appropriate action by the nurse is to a. refer the patient to a qualified genetic counselor. b. ask the patient why genetic testing is important to her. c. remind the patient that genetic testing has many social implications. d. tell the patient that cystic fibrosis is an autosomal-recessive disorder.

ANS: A A genetic counselor is best qualified to address the multiple issues involved in genetic testing for a patient who is considering having children. Although genetic testing does have social implications, a pregnant patient will be better served by a genetic counselor who will have more expertise in this area. CF is an autosomal-recessive disorder, but the patient might not understand the implications of this statement. Asking why the patient feels genetic testing is important may imply to the patient that the nurse is questioning her value system regarding issues such as abortion.

21. A patient is admitted to the hospital with acute rejection of a kidney transplant. The nurse will anticipate a. administration of immunosuppressant medications. b. insertion of an arteriovenous graft for hemodialysis. c. placement of the patient on the transplant waiting list. d. drawing blood for human leukocyte antigen (HLA) and ABO compatibility matching.

ANS: A Acute rejection is treated with the administration of additional immunosuppressant drugs such as corticosteroids. Because acute rejection is reversible, there is no indication that the patient will require another transplant, hemodialysis, or HLA/ABO testing.

5. A patient is being evaluated for possible atopic dermatitis. The nurse will review the patient's laboratory values for the level of a. IgE. b. IgA. c. basophils. d. neutrophils.

ANS: A Serum IgE causes the symptoms of allergic reactions and is elevated in type 1 hypersensitivity disorders. The eosinophil level will be elevated, rather than neutrophil or basophil counts. IgA is located in body secretions and would not be tested when evaluating a patient who has symptoms of atopic dermatitis.

7. The nurse discusses the prevention and management of allergic reactions with a beekeeper who has developed a hypersensitivity to bee stings. The nurse identifies a need for additional teaching when the patient states, a. "I will plan to take oral antihistamines daily before going to work." b. "I will get a prescription for epinephrine and learn to self-inject it." c. "I should wear a Medic Alert bracelet indicating my allergy to bee stings." d. "I am going to need job retraining so that I can work in a different occupation."

ANS: A Since the patient is at risk for bee stings and the severity of allergic reactions tends to increase with added exposure to allergen, taking oral antihistamines will not adequately control the patient's hypersensitivity reaction. The other patient statements indicate a good understanding of management of the problem.

14. A patient who received a bone marrow transplant for treatment of leukemia develops a skin rash 10 days after the transplant. The nurse recognizes this reaction as an indication that the a. donor T cells are attacking the patient's skin cells. b. patient's antibodies are rejecting the donor bone marrow. c. patient is experiencing a delayed hypersensitivity reaction. d. patient will need treatment to prevent hyperacute rejection.

ANS: A The patient's history and symptoms indicate that the patient is experiencing graft-versus-host disease, in which the donated T cells attack the patient's tissues. The history and symptoms are not consistent with rejection or delayed hypersensitivity

6. A 62-year-old patient who is having an annual check-up tells the nurse, "I don't understand why I need to have so many cancer screening tests now. I feel just fine!" The nurse will plan to teach the patient about the a. consequences of aging on cell-mediated immunity. b. decrease in antibody production associated with aging. c. impact of poor nutrition on immune function in older people. d. incidence of cancer-stimulating infections in older individuals.

ANS: A The primary impact of aging on immune function is on the activity of T cells, which are responsible for tumor immunity. Antibody function is not impacted as much by aging and does not protect against malignancy. Poor nutrition does contribute to decreased immunity, but there is no evidence that it is a contributing factor for this patient. Although some types of cancer are associated with specific infections, this patient does not have an active infection.

3. In counseling a couple in which the man has an autosomal recessive disorder, and the woman has no gene for the disorder, the nurse uses Punnett squares to show the couple that the probability of their having a child with the disorder is a. 0%. b. 25%. c. 50%. d. 75%.

ANS: A When one parent has no gene for an autosomal recessive disorder, the children will not display the characteristics of the disorder. However, the children will be carriers of the autosomal recessive disorder.

2. A patient seen in the outpatient clinic has an immune deficiency involving the T-lymphocytes. The nurse should teach the patient about the need for more frequent screening for a. allergies. b. malignancy. c. antibody deficiency. d. autoimmune disorders.

ANS: B Cell-mediated immunity is responsible for the recognition and destruction of cancer cells. Allergic reactions, autoimmune disorders, and antibody deficiencies are mediated primarily by humoral immunity.

11. A patient diagnosed with systemic lupus erythematosus (SLE) is scheduled for plasmapheresis. The nurse plans to teach the patient that plasmapheresis will a. eliminate eosinophils and basophils from blood. b. remove antibody-antigen complexes from circulation. c. prevent foreign antibodies from damaging various body tissues. d. decrease the damage to organs caused by attacking T-lymphocytes.

ANS: B Plasmapheresis is used in SLE to remove antibodies, antibody-antigen complexes, and complement from blood. T-lymphocytes, foreign antibodies, eosinophils, and basophils do not contribute to the tissue damage in SLE.

24. After being stung by a wasp, a patient is brought to the clinic by a co-worker. Upon arrival the patient is anxious and having difficulty breathing. The first action that the nurse should take is to a. have the patient lie down. b. assess the patient's airway. c. administer high-flow oxygen. d. remove the stinger from the site.

ANS: B The initial action with any patient with difficulty breathing is to assess and maintain the airway. The other actions also are part of the emergency management protocol for anaphylaxis, but the priority is airway maintenance

15. A patient seeks medical care after sharing needles for heroin injection with a friend who has hepatitis B. To provide immediate protection from infection, the nurse expects to administer a. corticosteroids. b. gamma globulin. c. hepatitis B vaccine. d. fresh frozen plasma.

ANS: B The patient should first receive antibodies for hepatitis B from injection of gamma globulin. The hepatitis B vaccination series should be started to provide active immunity. Fresh frozen plasma and corticosteroids will not be effective in preventing hepatitis B in the patient.

8. Which instruction will be included when teaching a patient with possible allergies about intradermal skin testing? a. "Do not eat anything for about 6 hours before the testing." b. "Take an oral antihistamine about an hour before the testing." c. "Plan to wait in the clinic for 20 to 30 minutes after the testing." d. "Reaction to the testing will take about 48 to 72 hours to occur."

ANS: C Allergic reactions usually occur within minutes after injection of an allergen, and the patient will be monitored for at least 20 minutes for anaphylactic reactions after the testing. Medications that might modify the response, such as antihistamines, should be avoided before allergy testing. There is no reason to be NPO for skin testing. Results with intradermal testing occur within minutes.

1. A patient whose mother has been diagnosed with BRCA gene-related breast cancer asks the nurse, "Do you think I should be tested for the gene?" Which response by the nurse is most appropriate? a. "In most cases, breast cancer is not caused by the BRCA gene." b. "It depends on how you will feel if the test is positive for the BRCA gene." c. "There are many things to consider before deciding to have genetic testing." d. "You should decide first whether you are willing to have a double mastectomy."

ANS: C Although presymptomatic testing for genetic disorders allows patients to take action (such as mastectomy) to prevent the development of some genetically caused disorders, patients also need to consider that test results in their medical file may impact insurance, employability, etc. Telling a patient that a decision about mastectomy should be made before testing implies that the nurse has made a judgment about what the patient should do if the test is positive. Although the patient may need to think about her reaction if the test is positive, other issues (e.g., insurance) also should be considered. Although most breast cancers are not related to BRCA gene alterations, the patient with the gene alteration has a markedly increased risk for breast cancer.

27. To determine whether a patient's angioedema has responded to prescribed therapies, which action should the nurse take first? a. Ask about any clear nasal discharge. b. Obtain blood pressure and heart rate. c. Check for swelling of the lips and tongue. d. Assess extremities for wheal and flare lesions.

ANS: C Angioedema is characterized by swelling of the eyelids, lips, and tongue. Wheal and flare lesions; clear nasal drainage; and hypotension and tachycardia are characteristic of other allergic reactions.

25. Immediately after the nurse administers an intracutaneous injection of an allergen on the forearm, a patient complains of itching at the site and of weakness and dizziness. The nurse should first a. remind the patient to remain calm. b. administer subcutaneous epinephrine. c. apply a tourniquet above the injection site. d. rub a local anti-inflammatory cream on the site.

ANS: C Application of a tourniquet will decrease systemic circulation of the allergen and should be the first reaction. A local anti-inflammatory cream may be applied to the site of a cutaneous test if the itching persists. Epinephrine will be needed if the allergic reaction progresses to anaphylaxis. The nurse should assist the patient to remain calm, but this is not an adequate initial nursing action.

9. A patient who receives weekly immunotherapy at a clinic missed the previous appointment. When the patient comes for the next injection, the nurse should a. schedule an additional dose that week. b. administer the usual dosage of the allergen. c. consult with the health care provider about giving a lower allergen dose. d. re-evaluate the patient's sensitivity to the allergen with a repeat skin test.

ANS: C Because there is an increased risk for adverse reactions after a patient misses a scheduled dose of allergen, the nurse should check with the health care provider before administration of the injection. A skin test is used to identify the allergen and would not be used at this time. An additional dose for the week may increase the risk for a reaction

4. The nurse encourages a new mother to breastfeed her infant, even for a short time, because ` will provide the infant with a. innate immunity. b. active immunity. c. passive immunity. d. cell-mediated immunity.

ANS: C Colostrum provides passive immunity through antibodies from the mother; these antibodies protect the infant for a few months. However, memory cells are not retained, so the protection is not permanent. Innate immunity is present at birth and occurs without exposure to an antigen. Active immunity requires that the infant manufacture antibodies after exposure to an antigen. Cell-mediated immunity is acquired through T-lymphocytes and is a form of active immunity.

28. Which information about patient and donor tissue typing results for a patient who needs a kidney transplant is most important for the nurse to communicate to the health care provider? a. Patient is Rh positive and donor is Rh negative. b. Six antigen matches are present in HLA typing. c. Results of patient-donor cross matching are positive. d. Panel of reactive antibodies (PRA) percentage is low.

ANS: C Positive crossmatching is an absolute contraindication to kidney transplantation, since hyperacute rejection will occur after the transplant. The other information indicates that the tissue match between the patient and potential donor is acceptable.

13. While the nurse is obtaining an assessment and health history from a patient, which statement by the patient will alert the nurse to a possible immunodeficiency disorder? a. "I take one baby aspirin every day to prevent stroke." b. "I usually eat eggs or meat for at least 2 meals a day." c. "I had my spleen removed many years ago after a car accident." d. "I had a chest x-ray 6 months ago when I had walking pneumonia."

ANS: C Splenectomy increases the risk for septicemia from bacterial infections. The patient's protein intake is good and should improve immune function. Daily aspirin use does not impact on immune function. A chest x-ray does not have enough radiation to suppress immune function.

16. After teaching a patient on immunosuppressant therapy after a kidney transplant about the posttransplant drug regimen, the nurse determines that additional teaching is needed when the patient says, a. "If I develop an acute rejection episode, I will need to have other types of drugs given IV." b. "I need to be monitored closely because I have a greater chance of developing malignant tumors." c. "After a couple of years, it is likely that I will be able to stop taking the calcineurin inhibitor." d. "The drugs are given in combination because they inhibit different aspects of transplant rejection."

ANS: C The calcineurin inhibitor will need to be continued for life. The other patient statements are accurate and indicate that no further teaching is necessary about those topics.

10. While obtaining a health history from the patient who works as a laboratory technician, the nurse learns that the patient has a history of allergic rhinitis, asthma, and multiple food allergies. It is important that the nurse a. encourage the patient to carry an epinephrine kit in case a type IV allergic reaction to latex develops. b. advise the patient to use oil-based hand creams to decrease contact with natural proteins in latex gloves. c. document the patient's allergy history and be alert for any clinical manifestations of a type I latex allergy. d. recommend that the patient use vinyl gloves instead of latex gloves in preventing blood-borne pathogen contact.

ANS: C The patient's allergy history and occupation indicate a risk for development of latex allergy, and the nurse should be prepared to manage any symptoms that occur. Epinephrine is not an appropriate treatment for contact dermatitis that is caused by a type IV allergic reaction to latex. Oil-based creams will increase the exposure to latex from latex gloves. Vinyl gloves are appropriate to use when exposure to body fluids is unlikely.

22. When the nurse is admitting a patient who has acute rejection of an organ transplant, which of these already admitted patients will be the most appropriate roommate? a. A patient who has viral pneumonia b. A patient with second degree burns c. A patient who is recovering from an anaphylactic reaction to a bee sting d. A patient with graft-versus-host disease after a recent bone marrow transplant

ANS: C Treatment for a patient with acute rejection includes administration of additional immunosuppressants, and the patient should not be exposed to increased risk for infection as would occur from patients with viral pneumonia, graft-versus-host disease, and burns. There is no increased exposure to infection from a patient with anaphylaxis.

29. Which information about a patient who is receiving immunotherapy and has just received an allergen injection is most important to communicate to the health care provider? a. The patient's IgG level is increased. b. The injection site is red and swollen. c. The patient's allergy symptoms have not improved. d. There is a 3-cm wheal at the site of the allergen injection.

ANS: D A local reaction larger than quarter size may indicate that a decrease in the allergen dose is needed. An increase in IgG indicates that the therapy is effective. Redness and swelling at the site are not unusual. Because immunotherapy usually takes 1 to 2 years to achieve an effect, an improvement in the patient's symptoms is not expected after a few months.

19. A man with mild hemophilia asks the nurse, "Will my children be hemophiliacs?" Which response by the nurse is appropriate? a. "All of your children will be at risk for hemophilia." b. "Hemophilia is a multifactorial inherited condition." c. "Only your male children are at risk for hemophilia." d. "Your female children will be carriers for hemophilia."

ANS: D Because hemophilia is caused by a mutation of the X-chromosome, all female children of a man with hemophilia are carriers of the disorder and can transmit the mutated gene to their offspring. Sons of a man with hemophilia will not have the disorder. Hemophilia is caused by a genetic mutation and is not a multifactorial inherited condition.

17. A patient has a new prescription for cyclosporine after having a kidney transplant. Which information in the patient's health history has the most implications for planning patient teaching about the medication at this time? a. The patient restricts salt to treat prehypertension. b. The patient drinks 3 to 4 quarts of fluids every day. c. The patient has many concerns about the effects of cyclosporine. d. The patient has a glass of grapefruit juice every day for breakfast.

ANS: D Grapefruit juice can increase the cyclosporine to toxic levels. The patient should be taught to avoid grapefruit juice. High fluid intake will not impact cyclosporine levels or renal function. Cyclosporine may cause hypertension, and the patient's many concerns should be addressed, but these are not potentially life-threatening problems.

26. When caring for a clinic patient who is experiencing an allergic reaction to an unknown allergen, which nursing activity is most appropriate for the RN to delegate to an LPN/LVN? a. Perform a focused physical assessment. b. Obtain the health history from the patient. c. Teach the patient about the various diagnostic studies. d. Administer skin testing by the cutaneous scratch method.

ANS: D LPN/LVNs are educated and licensed to administer medications under the supervision of an RN. RN-level education and the scope of practice include assessment of health history, focused physical assessment, and patient teaching.

12. The nurse will monitor a patient who is undergoing plasmapheresis for a. shortness of breath. b. high blood pressure. c. transfusion reactions. d. numbness and tingling.

ANS: D Numbness and tingling may occur as the result of the hypocalcemia caused by the citrate used to prevent coagulation. The other clinical manifestations are not associated with plasmapheresis.

20. A patient seen at the clinic with atopic dermatitis has a history of multiple allergies and several previous anaphylactic reactions. Which type of testing for allergens will the nurse anticipate for this patient? a. Serum IgE-level test b. Cutaneous scratch test c. Intracutaneous skin test d. Radioallergosorbent test (RAST)

ANS: D RAST is an in vitro test for hypersensitivity to specific allergens that is used when patients are likely to have anaphylactic reactions to other forms of skin testing. Cutaneous scratch testing or intracutaneous testing is more likely to cause anaphylaxis. Serum IgE level is elevated in atopic reactions but is not diagnostic for specific allergens.

23. For early detection of an anaphylactic reaction in a patient who has received allergen testing using the cutaneous scratch method, which action should the nurse take first? a. Check blood pressure and pulse rate. b. Auscultate the lung sounds bilaterally. c. Monitor pupil size and reaction to light. d. Assess the arm at the site of the skin testing.

ANS: D The initial symptoms of anaphylaxis are itching and edema at the site of the exposure. Hypotension, tachycardia, dilated pupils, and wheezes occur later. Rapid administration of epinephrine when excessive itching or swelling at the skin site is observed can prevent the progression to anaphylaxis.