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A patient is brought to the emergency department (ED) in a state of anaphylaxis. What is the ED nurses priority for care?
- A. Monitor the patients level of consciousness.
- B. Protect the patients airway.
- C. Provide psychosocial support.
- D. Administer medications as ordered.
Correct Answer: B
Rationale: Anaphylaxis severely threatens a patients airway; the nurses priority is preserving airway patency and breathing pattern. This is a higher priority than other valid aspects of care, including medication administration, psychosocial support, and assessment of LOC.
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A nurse has asked the nurse educator if there is any way to predict the severity of a patients anaphylactic reaction. What would be the nurses best response?
- A. The faster the onset of symptoms, the more severe the reaction.
- B. The reaction will be about one-third more severe than the patients last reaction to the same antigen.
- C. There is no way to gauge the severity of a patients anaphylaxis, even if it has occurred repeatedly in the past.
- D. The reaction will generally be slightly less severe than the last reaction to the same antigen.
Correct Answer: A
Rationale: The time from exposure to the antigen to onset of symptoms is a good indicator of the severity of the reaction: the faster the onset, the more severe the reaction. None of the other statements is an accurate description of the course of anaphylactic reactions.
A patient has developed severe contact dermatitis with burning, itching, cracking, and peeling of the skin on her hands. What should the nurse teach the patient to do?
- A. Wear powdered latex gloves when in public.
- B. Wash her hands with antibacterial soap every few hours.
- C. Maintain room temperature at 75 F to 80 F whenever possible.
- D. Keep her hands well-moisturized at all times.
Correct Answer: D
Rationale: Powdered latex gloves can cause contact dermatitis. Skin should be kept well-hydrated and should be washed with mild soap. Maintaining room temperature at 75 F to 80 F is not necessary.
A patient with a family history of allergies has suffered an allergic response based on a genetic predisposition. This atopic response is usually mediated by what immunoglobulin?
- A. Immunoglobulin A
- B. Immunoglobulin M
- C. Immunoglobulin G
- D. Immunoglobulin E
Correct Answer: D
Rationale: Atopy refers to allergic reactions characterized by the action of IgE antibodies and a genetic predisposition to allergic reactions.
A nurse is caring for a patient who has allergic rhinitis. What intervention would be most likely to help the patient meet the goal of improved breathing pattern?
- A. Teach the patient to take deep breaths and cough frequently.
- B. Use antihistamines daily throughout the year.
- C. Teach the patient to seek medical attention at the first sign of an allergic reaction.
- D. Modify the environment to reduce the severity of allergic symptoms.
Correct Answer: D
Rationale: The patient is instructed and assisted to modify the environment to reduce the severity of allergic symptoms or to prevent their occurrence. Deep breathing and coughing are not indicated unless an infection is present. Anaphylaxis requires prompt medical attention, but a minority of allergic reactions are anaphylaxis. Overuse of antihistamines reduces their effectiveness.
A nurse is caring for a teenage girl who has had an anaphylactic reaction after a bee sting. The nurse is providing patient teaching prior to the patients discharge. In the event of an anaphylactic reaction, the nurse informs the patient that she should self-administer epinephrine in what site?
- A. Forearm
- B. Thigh
- C. Deltoid muscle
- D. Abdomen
Correct Answer: B
Rationale: The patient is taught to position the device at the middle portion of the thigh and push the device into the thigh as far as possible. The device will autoinject a premeasured dose of epinephrine into the subcutaneous tissue.