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Immediately after the nurse administers an intradermal injection of an allergen on the forearm, a patient complains of itching at the site and of weakness and dizziness. Which of the following actions is priority for the nurse to implement?
- A. Remind the patient to remain calm.
- B. Administer subcutaneous epinephrine.
- C. Apply a tourniquet above the injection site.
- D. Rub a local anti-inflammatory cream on the site.
Correct Answer: C
Rationale: Application of a tourniquet will decrease systemic circulation of the allergen and should be the first reaction. A local anti-inflammatory cream may be applied to the site of a cutaneous test if the itching persists. Epinephrine will be needed if the allergic reaction progresses to anaphylaxis. The nurse should assist the patient to remain calm, but this is not an adequate initial nursing action.
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The nurse is caring for a patient who is receiving an IV antibiotic and develops wheezes and dyspnea. In which order should the nurse implement these prescribed actions?
- A. Discontinue the antibiotic infusion.
- B. Give diphenhydramine IV.
- C. Inject epinephrine IM.
- D. Start 100% oxygen using a nonrebreather mask.
Correct Answer: A,D,C,B
Rationale: The nurse should initially discontinue the antibiotic, since it is the likely cause of the allergic reaction. Next, oxygen delivery should be maximized, followed by treatment of bronchoconstriction with epinephrine administered IM or IV. Diphenhydramine will work more slowly than epinephrine, but will help prevent progression of the reaction.
Chickenpox is an example of which of the following types of immunities?
- A. Innate
- B. Natural active
- C. Artificial
- D. Cell-mediated
Correct Answer: B
Rationale: Chickenpox is an example of natural active immunity, as it is acquired through natural exposure to the varicella-zoster virus, leading to the production of antibodies and memory cells.
The nurse is obtaining a health history from a patient who works as a laboratory technician and learns that the patient has a history of allergic rhinitis, asthma, and multiple food allergies. Which of the following actions is most important for the nurse to implement?
- A. Encourage the patient to carry an epinephrine kit in case a type IV allergic reaction to latex develops.
- B. Advise the patient to use oil-based hand creams to decrease contact with natural proteins in latex gloves.
- C. Document the patient's allergy history and be alert for any clinical manifestations of a type I latex allergy.
- D. Recommend that the patient use vinyl gloves instead of latex gloves in preventing bloodborne pathogen contact.
Correct Answer: C
Rationale: The patient's allergy history and occupation indicate a risk for development of latex allergy, and the nurse should be prepared to manage any symptoms that occur. Epinephrine is not an appropriate treatment for contact dermatitis that is caused by a type IV allergic reaction to latex. Oil-based creams will increase the exposure to latex from latex gloves. Vinyl gloves are appropriate to use when exposure to body fluids is unlikely.
Which information about a patient who is receiving immunotherapy and has just received an allergen injection is most important to communicate to the health care provider?
- A. The patient's IgG level is increased.
- B. The injection site is red and swollen.
- C. The patient's allergy symptoms have not improved.
- D. There is a 3-cm wheal at the site of the allergen injection.
Correct Answer: D
Rationale: A local reaction larger than quarter size may indicate that a decrease in the allergen dose is needed. An increase in IgG indicates that the therapy is effective. Redness and swelling at the site are not unusual. Because immunotherapy usually takes 1-2 years to achieve an effect, an improvement in the patient's symptoms is not expected after a few months.
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.