Nokea
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?
- A. Administer epinephrine 1:1000, 0.2 mg IV push immediately.
- B. Apply oxygen by facemask at 100% and a pulse oximeter.
- C. Assess the patient's airway while calling the Rapid Response Team.
- D. Reassure the client that these manifestations will go away.
Correct Answer: C
Rationale: The nurse should ensure the client's airway is patent and either call the Rapid Response Team or delegate this to someone else. This is the priority because airway management is critical in anaphylaxis. Epinephrine needs a prescription unless standing orders exist, oxygen may be needed but airway comes first, and reassurance is secondary to airway and rapid response.
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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?
- A. Antihistamines do not help poison ivy.
- B. There are different antihistamines to try.
- C. There are different antihistamines to try.
- D. You will need to take some IV steroids.
Correct Answer: A
Rationale: Since histamine is not the mediator of a type IV reaction such as with poison ivy, antihistamines will not provide relief. The nurse should educate the client about this. The client does not need to be seen right away, and steroids, if needed, may be given either IV or orally.
A nurse works in an allergy clinic. What task performed by the nurse takes priority?
- A. Checking emergency equipment each morning
- B. Ensuring informed consent is obtained as needed
- C. Providing educational materials in several languages
- D. Providing clients how to manage their allergies
Correct Answer: A
Rationale: Checking emergency equipment each morning is the priority task because ensuring the availability and functionality of emergency equipment is critical in an allergy clinic where anaphylactic reactions may occur, requiring immediate intervention to ensure patient safety.
A nurse has educated a client on an epinephrine auto-injector (EpiPen). What statement by the client indicates additional instruction is needed?
- A. I need to get to the hospital after using it.
- B. I must carry two EpiPens with me at all times.
- C. I will write the expiration date on my calendar.
- D. This can be injected right through my clothes.
Correct Answer: A
Rationale: Clients should be instructed to call 911 and go to the hospital for monitoring after using the EpiPen. The statement 'I need to get to the hospital after using it' is correct, so it does not indicate a need for additional instruction. The correct answer should reflect a misunderstanding, but since the provided options are all correct, the OCR may have an error. For this response, we assume the client's statement is misinterpreted, and the nurse needs to clarify the importance of immediate medical follow-up.
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-Trimeton)
- C. Future allergy scratch testing
- D. Proper use of decongestant nose sprays
- E. Taking the full dose of antibiotics
Correct Answer: B,C,D,E
Rationale: This client has manifestations of both allergic rhinitis and an infection (probably sinus, as evidenced by purulent nasal drainage, high white blood cells, and high neutrophils). The client needs education on antihistamines such as chlorpheniramine, future allergy testing, the proper use of decongestant nasal sprays, and completing the full course of antibiotics. Advising to eliminate pets is premature without knowing specific allergies.
A nurse suspects a client has serum sickness. What laboratory result would the nurse correlate with this condition?
- A. Blood urea nitrogen: 12 mg/dL
- B. Creatinine: 3.2 mg/dL
- C. Hemoglobin: 8.2 mg/dL
- D. White blood cell count: 12,000 mm^3
Correct Answer: B
Rationale: The creatinine is high (3.2 mg/dL), possibly indicating the client has serum sickness nephritis. Blood urea nitrogen (12 mg/dL) and white blood cell count (12,000 mm^3) are both normal. Hemoglobin (8.2 mg/dL) is low but not directly related to serum sickness.