Nokea
The nurse is admitting a patient to hospital who has acute rejection of an organ transplant. Which of the following patients is the most appropriate roommate?
- A. A patient who has viral pneumonia
- B. A patient with second-degree burns
- C. A patient who is recovering from an anaphylactic reaction to a bee sting
- D. A patient with graft-versus-host disease after a recent bone marrow transplant
Correct Answer: C
Rationale: Treatment for a patient with acute rejection includes administration of additional immunosuppressants, and the patient should not be exposed to increased risk for infection as would occur from patients with viral pneumonia, graft-versus-host disease, and burns. There is no increased exposure to infection from a patient with anaphylaxis.
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Which of the following adverse reactions should the nurse monitor when a patient is undergoing plasmapheresis?
- A. Shortness of breath
- B. High blood pressure
- C. Transfusion reactions
- D. Hypotension and paresthesia
Correct Answer: D
Rationale: Hypotension and paresthesia may occur as the result of plasmapheresis. Citrate is used as an anticoagulant and may cause hypocalcemia, which may manifest as headache, paresthesias, and dizziness. The other clinical manifestations are not associated with plasmapheresis.
The nurse discusses the prevention and management of allergic reactions with a patient who is a beekeeper and has developed a hypersensitivity to bee sting. Which of the following patient statements indicates a need for additional teaching?
- A. I will plan to take oral antihistamines daily before going to work.'
- B. I will get a prescription for epinephrine and learn to self-inject it.'
- C. I should wear a Medic Alert bracelet indicating my allergy to bee stings.'
- D. I am going to need job retraining so that I can work in a different occupation.'
Correct Answer: A
Rationale: Since the patient is at risk for bee stings and the severity of allergic reactions tends to increase with added exposure to allergen, taking oral antihistamines will not adequately control the patient's hypersensitivity reaction. The other patient statements indicate a good understanding of management of the problem.
The nurse is completing an assessment and health history with a patient. Which of the following statements made by the patient should alert the nurse to a possible immunodeficiency disorder?
- A. I take one baby Aspirin every day to prevent stroke.'
- B. I usually eat eggs or meat for at least two meals a day.'
- C. I had my spleen removed many years ago after a car accident.'
- D. I had a chest x-ray 6 months ago when I had walking pneumonia.'
Correct Answer: C
Rationale: Splenectomy increases the risk for septicemia from bacterial infections. The patient's protein intake is good and should improve immune function. Daily Aspirin use does not impact immune function. A chest x-ray does not have enough radiation to suppress immune function.
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.
For early detection of an anaphylactic reaction in a patient who has received allergen testing using the cutaneous scratch method, which of the following actions should the nurse take first?
- A. Check blood pressure and pulse rate.
- B. Auscultate the lung sounds bilaterally.
- C. Monitor pupil size and reaction to light.
- D. Assess the arm at the site of the skin testing.
Correct Answer: D
Rationale: The initial symptoms of anaphylaxis are itching and edema at the site of the exposure. Hypotension, tachycardia, dilated pupils, and wheezes occur later. Rapid administration of epinephrine when excessive itching or swelling at the skin site is observed can prevent the progression to anaphylaxis.