Nokea
The nurse is caring for a patient who had a bone marrow transplant for treatment of leukemia and has developed a skin rash 10 days after the transplant. The nurse recognizes this reaction as an indication of which of the following?
- A. Donor T cells are attacking the patient's skin cells.
- B. The patient's antibodies are rejecting the donor bone marrow.
- C. The patient is experiencing a delayed hypersensitivity reaction.
- D. The patient will need treatment to prevent hyperacute rejection.
Correct Answer: A
Rationale: The patient's history and symptoms indicate that the patient is experiencing graft-versus-host disease, in which the donated T cells attack the patient's tissues. The history and symptoms are not consistent with rejection or delayed hypersensitivity.
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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.
To determine whether a patient's angioedema has responded to prescribed therapies, which of the following actions should the nurse take first?
- A. Ask about any clear nasal discharge.
- B. Obtain blood pressure and heart rate.
- C. Check for swelling of the lips and tongue.
- D. Assess extremities for wheal and flare lesions.
Correct Answer: C
Rationale: Angioedema is characterized by swelling of the eyelids, lips, and tongue. Wheal and flare lesions, clear nasal drainage, and hypotension and tachycardia are characteristics of other allergic reactions.
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.
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.
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.