Chapter 20 Flashcards
A nurse works in an allergy clinic. What task performed by the nurse takes priority?
Checking emergency equipment each morning
A client is in the preoperative holding area prior to surgery. The nurse notes that the client has allergies to avocados and strawberries. What action by the nurse is best?
Ensure the information is relayed to the surgical team.
The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction?
Correctly identifying the client prior to a blood transfusion
A nurse suspects a client has serum sickness. What laboratory result would the nurse correlate with this condition?
Creatinine: 3.2 mg/dL
A client calls the clinic to report exposure to poison ivy and an itchy rash that is not helped with over-the-counter antihistamines. What response by the nurse is most appropriate?
“Antihistamines do not help poison ivy.”
A client with Sjögren’s syndrome reports dry skin, eyes, mouth, and vagina. What nonpharmacologic comfort measure does the nurse suggest?
Home humidifier
A client is receiving plasmapheresis as treatment for Goodpasture’s syndrome. When planning care, the nurse places highest priority on interventions for which client problem?
Potential for infection related to the site for organism invasion
A nurse has educated a client on an epinephrine auto-injector (EpiPen). What statement by the client indicates additional instruction is needed?
“I don’t need to go to the hospital after using it.”
A client having severe allergy symptoms has received several doses of IV antihistamines. What action by the nurse is most important?
Instruct the client not to get up without help.
A client is in the hospital and receiving IV antibiotics. When the nurse answers the client’s call light, the client presents an appearance as shown below:
What action by the nurse takes priority?
Ensure a patent airway while calling the Rapid Response Team.
The nursing student is studying hypersensitivity reactions. Which reactions are correctly matched with their hypersensitivity types? (Select all that apply.)
a. Type I – Examples include hay fever and anaphylaxis
b. Type II – Mediated by action of immunoglobulin M (IgM)
c. Type III – Immune complex deposits in blood vessel walls
d. Type IV – Examples are poison ivy and transplant rejection
e. Type V – Examples include a positive tuberculosis test and sarcoidosis
A,C,D
A client in the family practice clinic reports a 2-week history of an “allergy to something.” The nurse obtains the following assessment and laboratory data:
Physical Assessment Data
Laboratory Results
Reports sore throat, runny nose, headache
Posterior pharynx is reddened
Nasal discharge is seen in the back of the throat
Nasal discharge is creamy yellow in color
Temperature 100.2° F (37.9° C)
Red, watery eyes
White blood cell count: 13,400/mm3
Eosinophil count: 11.5%
Neutrophil count: 82%
About what medications and interventions does the nurse plan to teach this client? (Select all that apply.)
a. Elimination of any pets
b. Chlorpheniramine (Chlor-Trimaton)
c. Future allergy scratch testing
d. Proper use of decongestant nose sprays
e. Taking the full dose of antibiotics
B,C,D,E
