Nokea
The nurse arrives at the bedside of a patient who has had a unit of packed cells infusing in his right arm for 35 minutes. He is complaining of chills, itching, and shortness of breath. What will be the nurse's initial action?
- A. Cover with a warm blanket.
- B. Take the patient's temperature.
- C. Elevate the head of the bed.
- D. Stop the transfusion and continue with saline.
Correct Answer: D
Rationale: Moderate reactions, resulting in fever, chills, urticaria, and wheezing, occur after the first 30 minutes of administration. In the event of a moderate reaction, stop the transfusion, continue with saline, and notify the health care provider. Elevation of the head, taking vital signs, and covering with a warm blanket are not wrong, but are not of primary importance.
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Which concern is a major negative effect of cell-mediated immunity?
- A. Depression of bone marrow
- B. Rejection of transplanted tissue
- C. Activation of the T cells
- D. Stimulation of the B cells
Correct Answer: B
Rationale: Cell-mediated immunity has the negative effect of rejection of transplanted tissue. Activation of T cells and stimulation of B cells are the positive basis of the cell-mediated immunity.
Immediately after the nurse administers an intradermal injection of a suspected antigen during allergy testing, the patient complains of itching at the site, weakness, and dizziness. Which action by the nurse is most appropriate initially?
- A. Elevate the arm above the shoulder.
- B. Administer subcutaneous epinephrine.
- C. Apply a warm compress to area.
- D. Apply a local antiinflammatory cream to the site.
Correct Answer: B
Rationale: Injection of subcutaneous epinephrine should be given at the first sign of allergy.
The nurse recommends to the busy parent of three young children that the antihistamine fexofenadine would be more beneficial than diphenhydramine because fexofenadine has which quality?
- A. is inexpensive.
- B. contains a stimulant for an energy boost.
- C. does not dry out the mucous membranes.
- D. does not induce drowsiness.
Correct Answer: D
Rationale: Allegra does not induce drowsiness as does Benadryl.
In which patient will the nurse be most concerned about immunodeficiency disorder?
- A. The patient taking desensitization injections (immunotherapy)
- B. The patient on long-term radiation therapy for cancer
- C. The overweight patient
- D. The patient recently diagnosed with lupus erythematosus
Correct Answer: B
Rationale: Radiation destroys lymphocytes and depletes the stem cells. Prolonged radiation depresses the bone marrow.
What is B-cell proliferation dependent on?
- A. Presence of NK (natural killer) cells
- B. Complement system
- C. Antigen stimulation
- D. Lymphokines
Correct Answer: C
Rationale: Antigen stimulation is the sole focus of B-cell proliferation.