Nokea
A client has an allergic reaction to seafood with generalized edema and reports being unable to get a wedding ring off as it is too tight. The client was unable to remove it with soap and water. What action by the nurse can facilitate removal of the ring without damaging it?
- A. Administer a diuretic and wait for the swelling to go down.
- B. There is not another option other than to use a ring cutter to remove the ring.
- C. Use twine to wrap the finger and, when the tissue is compressed, pull the free end of the twine and remove the ring.
- D. Use a tongue blade to remove the ring.
Correct Answer: C
Rationale: If applying soap or oil to the finger proves unsuccessful, the nurse may wrap the finger with twine. Once the tissue is compressed, the ring can be removed by pulling on the free end of the twine. This technique is preferable to damaging the ring with a metal cutter. If nothing else facilitates ring removal, however, cutting the ring is a better option than allowing damage from ischemia to develop. The nurse cannot administer a diuretic without a physician's prescription, and allowing the swelling to go down may cause tissue ischemia from the constricted ring. There are options other than cutting the ring, but if they fail, there is no other choice. A tongue blade will not remove a ring that is too tight.
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The nurse is collecting data from a client with the autoimmune disorder endocarditis. What does the nurse recognize as symptom of an acute exacerbation?
- A. Temperature of 100.9?°F
- B. Respiratory rate of 20 breaths/minute
- C. Constipation
- D. Nausea
Correct Answer: A
Rationale: Periods of acute flare-ups (known as exacerbations) are completely unpredictable. During acute exacerbations, clients often experience a low-grade fever, malaise, or fatigue. They also may lose weight. A respiratory rate of 20 breaths/minute is within normal range. Constipation and nausea are not characteristic of a flare-up of endocarditis.
The nurse is interviewing a client being admitted to the hospital and inquires about any allergies the client has. The client reports being allergic to aspirin and penicillin. What intervention should the nurse provide immediately to prevent complications related to allergies?
- A. Apply an allergy bracelet and flag the chart.
- B. Tape an EpiPen to the head of the bed.
- C. Inform the client not to take any medications with those substances in them.
- D. Call the physician.
Correct Answer: A
Rationale: The nurse asks each client about the existence of any allergies. If any are reported, the nurse flags the medical record and applies a wristband with the appropriate information. Throughout the client's care, the nurse observes for signs of an allergic reaction, especially when administering medication, applying substances such as tape or adhesive patches to the skin. Medication should never be left in the client's room. The responsibility for medications with the identified allergens lies with the healthcare personnel in the acute care facility. The physician does not need to be called if the chart is flagged.
A client comes to the clinic and reports having had a mild case of the flu a couple of months ago and not having felt well since. The client expresses feeling fatigued that gets worse after any physical activity and having a recurrent sore throat and joint pain. What does the nurse recognize these symptoms may indicate?
- A. Chronic fatigue syndrome
- B. Rheumatoid arthritis
- C. Ulcerative colitis
- D. Recurrent flu
Correct Answer: A
Rationale: Many clients with CFS report having had a recent illness with flulike symptoms or an upper respiratory infection. Despite having been uncomfortable, most clients do not describe their initial symptoms as being extraordinarily severe. Severe, ongoing fatigue lasts for at least 6 months without any explanation. Even though the fatigue is constant, it worsens after physical activity. The fatigue is so debilitating that it usually interferes with a person's ability to work in or outside the home. Rheumatoid arthritis and ulcerative colitis are autoimmune disorders with symptoms that are more specific than CFS and can be diagnosed with diagnostic testing and laboratory studies. The symptoms that the client is having are not characteristic of the flu.
A client is in treatment for an allergic disorder. What might the treatment be?
- A. Autoimmune therapy
- B. Hypersensitive therapy
- C. Desensitization therapy
- D. Drug therapy for symptoms
Correct Answer: D
Rationale: Besides avoiding the allergen if possible, many clients experience symptomatic relief with drug therapy. It is not likely the client would be in autoimmune, hypersensitive, or desensitization therapy for an allergic disorder.
A client comes to the clinic and reports having 'broken out in hives and itching since eating strawberries this morning.' The client states never having had problems with strawberries before. What is the best response by the nurse?
- A. It is probably not the strawberries that you are having an allergy to if you have eaten them before.'
- B. It is possible to develop an allergic reaction to something you have had prior exposure to previously.'
- C. Are you sure that you haven't had an allergic reaction before; this doesn't seem possible.'
- D. We will probably be admitting you to the hospital; this could cause respiratory arrest.'
Correct Answer: B
Rationale: Allergies can occur at any age, and the pattern of allergic response can vary in the same person at different points in life. For example, a person may suddenly develop an allergic reaction to a substance such as latex, despite having had multiple prior contacts with latex and no past problems. Although an allergic reaction may cause laryngeal swelling, this client does not exhibit any of the signs and symptoms of respiratory distress that would lead to respiratory arrest.