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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.
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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.
The nurse is teaching a patient on immunosuppressant therapy after a kidney transplant about the post-transplant drug regimen. Which of the following statements by the patient should alert the nurse that additional teaching is required?
- A. If I develop an acute rejection episode, I will need to have other types of drugs given IV.'
- B. I need to be monitored closely because I have a greater chance of developing malignant tumours.'
- C. After a couple of years, it is likely that I will be able to stop taking the calcineurin inhibitor.'
- D. The drugs are given in combination because they inhibit different aspects of transplant rejection.'
Correct Answer: C
Rationale: The calcineurin inhibitor will need to be continued for life. The other patient statements are accurate and indicate that no further teaching is necessary about those topics.
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 of the following instructions should the nurse include when teaching a patient with possible allergies about intradermal skin testing?
- A. Do not eat anything for about 6 hours before the testing.'
- B. Take an oral antihistamine about an hour before the testing.'
- C. Plan to wait in the clinic for 20-30 minutes after the testing.'
- D. Reaction to the testing will take about 48-72 hours to occur.'
Correct Answer: C
Rationale: Allergic reactions usually occur within minutes after injection of an allergen, and the patient will be monitored for at least 20 minutes for anaphylactic reactions after the testing. Medications that might modify the response, such as antihistamines, should be avoided before allergy testing. There is no reason to be NPO for skin testing. Results with intradermal testing occur within minutes.
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.