Nokea
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.
You may also like to solve these questions
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.
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.
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.
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 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.