1. Which characteristic is common to all types of hypersensitivity
reactions?
a. |
Decreased inflammatory
responses |
b. |
Presence of
tissue-damaging reactions |
c. |
Enhanced natural
killer cell activity |
d. |
Inability to recognize
extraneous cells |
ANS: B
The defining difference
between a normal immune response and that termed hypersensitivity is
that the immune system reacts excessively or inappropriately, with resultant
tissue damage and pathology.
DIF: Cognitive Level:
Knowledge/Remembering REF: p. 383
TOP: Client Needs
Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process:
Nursing Process (Assessment)
2. What intervention does the nurse implement to
provide for client safety during intradermal allergy testing?
a. |
Stay with the client
and ensure that emergency equipment is in the room. |
b. |
Pretreat the skin area
to be tested with a cortisone-based cream. |
c. |
Apply oxygen by mask
or nasal cannula before injecting the test agent. |
d. |
Cover the examination
table and pillow with plastic or an ultrafine mesh. |
ANS: A
Although it is usually a
safe procedure, intradermal testing increases the risk for an adverse reaction,
including anaphylaxis. Emergency equipment should be available. Pretreating the
skin with cortisone will not decrease the risk of anaphylaxis. Applying oxygen
will not help prevent a reaction. Covering the examination table will also not
prevent allergic reactions.
DIF: Cognitive Level:
Application/Applying or higher REF: N/A
TOP: Client Needs Category:
Physiological Integrity (Reduction of Risk Potential—Potential for
Complications from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process:
Nursing Process (Implementation)
3. What is most important for the nurse to teach
the client with allergic rhinitis and glaucoma?
a. |
“If your heartbeat increases, be sure to
contact your health care provider.” |
b. |
“Avoid allergy drugs containing pseudoephedrine
or phenylephrine.” |
c. |
“Be sure to drink plenty of water with antihistamines.” |
d. |
“You should use an eye-moistening agent such as
Restasis.” |
ANS: B
Ephedrine,
phenylephrine, and pseudoephedrine may cause vasoconstriction, increase blood
pressure, and increase intraocular pressure. The client should avoid these drugs.
An increased heart rate is not a reason to call the health care provider. The
client may be thirstier when on allergy medications, or the client may need an
eye-moistening agent, but these are not the most important things for the nurse
to teach.
DIF: Cognitive Level:
Application/Applying or higher REF: N/A
TOP: Client Needs
Category: Physiological Integrity (Pharmacological and Parenteral
Therapies—Adverse Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process:
Nursing Process (Implementation)
4. A client has received diphenhydramine (Benadryl)
and is currently oriented but drowsy. What is the best action for the nurse to
take?
a. |
Perform a neurologic
assessment every 2 hours. |
b. |
Document the response
and continue to monitor. |
c. |
Prepare to administer
epinephrine subcutaneously. |
d. |
Have the nursing
assistant stimulate the client every hour. |
ANS: B
The client is
experiencing normal side effects of the medication. The nurse will continue to
monitor for additive effects. Performing a neurologic assessment is not
necessary, nor is administration of epinephrine. There is no reason for the
client to be stimulated hourly.
DIF: Cognitive Level:
Application/Applying or higher REF: N/A
TOP: Client Needs
Category: Physiological Integrity (Pharmacological and Parenteral
Therapies—Adverse Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process:
Nursing Process (Implementation)
5. Which condition is a type II hypersensitivity
reaction?
a. |
Allergic rhinitis |
b. |
Positive purified
protein derivative (PPD) test for tuberculosis |
c. |
Transfusion reaction
to improper blood type |
d. |
Serum sickness after
receiving immune globulin |
ANS: C
Common clinical
situations caused by type II hypersensitivities include hemolytic transfusion
reactions. Type II hypersensitivity reactions are caused by antibodies directed
against body tissues that have some form of non-self (foreign) protein attached
to them. Allergic rhinitis is an example of a type I hypersensitivity. A positive
PPD test is an example of a type IV reaction. Serum sickness is a type III
reaction.
DIF: Cognitive Level:
Knowledge/Remembering REF: p. 391
TOP: Client Needs
Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process:
Nursing Process (Assessment)
6. A client is receiving an IV infusion of an
antibiotic. The client calls the nurse about feeling uneasy and uncomfortable
owing to congestion. Which action by the nurse is most appropriate?
a. |
Elevate the head of
the client’s bed to 45 degrees. |
b. |
Have another nurse
call the Rapid Response Team. |
c. |
Prepare to administer
diphenhydramine (Benadryl). |
d. |
Slow the rate of the
IV infusion. |
ANS: B
This client has early
signs of anaphylaxis. The nurse must notify the Rapid Response Team but also
needs to stay with the client in case of cardiovascular collapse. The nurse’s
best action is to ask another nurse to call the Team while he or she continues
to assess the client. The nurse will prepare to administer epinephrine. Slowing
the IV rate will not help the situation; if the client is reacting to the
antibiotic, the nurse should change the IV tubing and solution. If the client
is not hypotensive, the nurse can raise the head of the bed.
DIF: Cognitive Level: Application/Applying
or higher REF: N/A
TOP: Client Needs
Category: Physiological Integrity (Physiological Adaptation—Medical
Emergencies) MSC: Integrated Process: Nursing Process (Implementation)
Category | ATI |
Release date | 2021-09-14 |
Pages | 14 |
Language | English |
Comments | 0 |
Sales | 0 |
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