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A client received 2 units of packed red blood cells while in the hospital with rectal bleeding. Three days after discharge, the client experienced an allergic response and began to itch and break out with hives. What type of reaction does the nurse understand could be occurring?
- A. Delayed hypersensitivity response
- B. Anaphylactic reaction
- C. Sensitization
- D. An immediate hypersensitivity response
Correct Answer: A
Rationale: A delayed hypersensitivity response may develop over several hours or days, or it may reach maximum severity after repeated exposure. Examples of a delayed hypersensitivity response include a blood transfusion reaction that occurs days to weeks after blood administration, rejection of transplanted tissues, and reaction to a tuberculin skin test. Anaphylaxis is a rapid and profound type I hypersensitivity response. Sensitization is the process by which cellular and chemical events occur after a second or subsequent exposure to an allergen. An immediate hypersensitivity response is due to antibodies interacting with allergens and occurs rapidly.
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The nurse is talking with a client who was stung by a bee and began having difficulty breathing. What serious complication from injected venom should the nurse discuss with the client?
- A. Hives
- B. Itching
- C. Airway obstruction
- D. Diarrhea
Correct Answer: C
Rationale: Injectants, such as bee venom, and some other allergens can produce systemic and potentially fatal effects, including shock and airway obstruction caused by laryngeal swelling. Although all other answers can occur with an allergen, they are not the most serious complication.
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.
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.
A client is taking a corticosteroid for the treatment of systemic lupus erythematosus. When the nurse is providing instructions about the medication to the client, what priority information should be included?
- A. If the client experiences nausea, omit the dose.
- B. The client should be alert for joint aches.
- C. This medication is commonly used for many inflammatory reactions and is relatively safe.
- D. Be alert for signs and symptoms of infection and report them immediately to the physician.
Correct Answer: D
Rationale: Instruct the client about signs and symptoms of and the increased risk for infection. Instruct the client to report signs and symptoms of infection immediately to the physician. Early treatment promotes a shorter duration of illness and reduced complication. Tell the client to avoid high-risk activities, such as being in crowds, during periods of immunosuppression. The client should not omit a dose if nausea is experienced but instead may take the medication with food. There are many side effects and required laboratory work to detect the side effects from immunosuppressive therapy. Joint aches are vague symptoms and are not a priority for reporting purposes.
A client informs the nurse of being very allergic to poison ivy but expresses enjoying and having several camping trips planned for the summer months. What suggestions can the nurse make to protect the client against poison ivy?
- A. Calamine lotion prior to the exposure of the poison ivy and any time skin gets wet
- B. Bentoquatam 5% applied 15 minutes prior to exposure and every 4 hours
- C. Vinegar and water applied to the skin every 2 hours
- D. Diphenhydramine (Benadryl) 50 mg taken prior to the camping trip
Correct Answer: B
Rationale: To protect against poison ivy, clients can apply bentoquatam 5% to the skin 15 minutes prior to exposure and at least every 4 hours as long as risk of exposure continues. The cream forms a protective layer on top of the skin. Calamine lotion can be used for the itching related to poison ivy exposure. Vinegar and water is not an effective way to manage the prevention of poison ivy. Benadryl will not protect against poison ivy.