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After being stung by a wasp, a patient is brought to the clinic by a coworker. Upon arrival the patient is anxious and having difficulty breathing. Which of the following actions is priority for the nurse to implement?
- A. Have the patient lie down.
- B. Assess the patient's airway.
- C. Administer high-flow oxygen.
- D. Remove the stinger from the site.
Correct Answer: B
Rationale: The initial action with any patient with difficulty breathing is to assess and maintain the airway. The other actions also are part of the emergency management protocol for anaphylaxis, but the priority is airway maintenance.
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The nurse is caring for a patient in the outpatient clinic who has an immune deficiency involving the T-lymphocytes. Which of the following areas should the nurse teach the patient about the need for more frequent screening?
- A. Allergies
- B. Malignancy
- C. Antibody deficiency
- D. Autoimmune disorders
Correct Answer: B
Rationale: Cell-mediated immunity is responsible for the recognition and destruction of cancer cells. Allergic reactions, autoimmune disorders, and antibody deficiencies are mediated primarily by humoral immunity.
The nurse is caring for a patient at an outpatient clinic who is experiencing an allergic reaction to an unknown allergen. Which of the following actions is most appropriate for the nurse to implement?
- A. Perform a focused physical assessment.
- B. Obtain the health history from the patient.
- C. Teach the patient about the various diagnostic studies.
- D. Prioritize care based on the presenting symptoms, starting with vital sign interpretation.
Correct Answer: D
Rationale: The immediate priority is to determine the status of the patient. After the allergic reaction is treated, an assessment of health history, focused physical assessment, and patient teaching could follow.
Which of the following antibodies is involved with an anaphylactic reaction?
- A. IgE
- B. IgA
- C. IgM
- D. IgG
Correct Answer: A
Rationale: Serum IgE causes the symptoms of allergic reactions and is the antibody involved with an anaphylactic reaction.
The nurse is caring for a patient who receives weekly immunotherapy and has missed the previous appointment. Which of the following actions should the nurse implement when the patient comes for the next injection?
- A. Schedule an additional dose that week.
- B. Administer the usual dosage of the allergen.
- C. Consult with the health care provider about giving a lower allergen dose.
- D. Re-evaluate the patient's sensitivity to the allergen with a repeat skin test.
Correct Answer: C
Rationale: Because there is an increased risk for adverse reactions after a patient misses a scheduled dose of allergen, the nurse should check with the health care provider before administration of the injection. A skin test is used to identify the allergen and would not be used at this time. An additional dose for the week may increase the risk for a reaction.
Which information about patient and donor tissue typing results for a patient who needs a kidney transplant is most important for the nurse to communicate to the health care provider?
- A. Patient is Rh positive and donor is Rh negative.
- B. Six antigen matches are present in HLA typing.
- C. Results of patient-donor crossmatching are positive.
- D. Panel of reactive antibodies (PRA) percentage is low.
Correct Answer: C
Rationale: Positive crossmatching is an absolute contraindication to kidney transplantation, since hyperacute rejection will occur after the transplant. The other information indicates that the tissue match between the patient and potential donor is acceptable.