Nokea
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?
- A. Reduced physical activity related to the disease's effects on the lungs
- B. Inadequate family coping with the client's hospitalization
- C. Inadequate knowledge related to the plasmapheresis process
- D. Potential for infection related to the site for organism invasion
Correct Answer: D
Rationale: The client has a potential for infection because plasmapheresis is an invasive procedure, making infection prevention the highest priority. Physical diagnoses, such as infection risk, take precedence over psychosocial diagnoses like inadequate family coping or knowledge deficits. There is no information indicating reduced physical activity.
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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.
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 client with Sjögren's syndrome reports dry skin, eyes, mouth, and vagina. What nonpharmacologic comfort measure does the nurse suggest?
- A. Home moisturizer
- B. Home humidifier
- C. Strong moisturizer
- D. Strong plug.
Correct Answer: B
Rationale: A humidifier will help relieve many of the client's Sjögren's syndrome symptoms by adding moisture to the air, which can alleviate dryness in the skin, eyes, mouth, and other mucous membranes. Eyedrops and tear duct plugs only affect the eyes, and moisturizer will only help the skin.
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 client suffered an episode of anaphylaxis and has been stabilized in the intensive care unit. When assessing the client's lungs, the nurse hears the following sounds. What medication does the nurse prepare to administer?
- A. Albuterol (Proventil) via nebulizer
- B. Diphenhydramine (Benadryl) IV
- C. Epinephrine 1:1000 IM
- D. Corticosteroids (Prednisone) oral
Correct Answer: A
Rationale: The presence of wheezing or abnormal lung sounds post-anaphylaxis suggests bronchoconstriction, for which albuterol via nebulizer is the appropriate treatment to relieve airway obstruction. Diphenhydramine addresses histamine-mediated symptoms, epinephrine is for acute anaphylaxis, and corticosteroids are for long-term inflammation control, not immediate relief.