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The nurse is interviewing a client being admitted to the hospital and inquires about any allergies the client has. The client reports being allergic to aspirin and penicillin. What intervention should the nurse provide immediately to prevent complications related to allergies?
- A. Apply an allergy bracelet and flag the chart.
- B. Tape an EpiPen to the head of the bed.
- C. Inform the client not to take any medications with those substances in them.
- D. Call the physician.
Correct Answer: A
Rationale: The nurse asks each client about the existence of any allergies. If any are reported, the nurse flags the medical record and applies a wristband with the appropriate information. Throughout the client's care, the nurse observes for signs of an allergic reaction, especially when administering medication, applying substances such as tape or adhesive patches to the skin. Medication should never be left in the client's room. The responsibility for medications with the identified allergens lies with the healthcare personnel in the acute care facility. The physician does not need to be called if the chart is flagged.
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A client with lupus has had antineoplastic drugs prescribed. Why would the physician prescribe antineoplastic drugs for an autoimmune disorder?
- A. To decrease the body's risk of infection
- B. Because an autoimmune disease is a neoplastic disease.
- C. So the client has strong drug therapy
- D. For their immunosuppressant effects
Correct Answer: D
Rationale: Drug therapy using anti-inflammatory and immunosuppressive agents is the mainstay for alleviating symptoms. Some antineoplastic (cancer) drugs also are used for their immunosuppressant effects. Antineoplastic drugs do not decrease the body's risk of infection; an autoimmune disease is not a neoplastic disease. Drugs are not prescribed just so the client has strong drug therapy.
A client informs the nurse of being very allergic to poison ivy but expresses enjoying and having several camping trips planned for the summer months. What suggestions can the nurse make to protect the client against poison ivy?
- A. Calamine lotion prior to the exposure of the poison ivy and any time skin gets wet
- B. Bentoquatam 5% applied 15 minutes prior to exposure and every 4 hours
- C. Vinegar and water applied to the skin every 2 hours
- D. Diphenhydramine (Benadryl) 50 mg taken prior to the camping trip
Correct Answer: B
Rationale: To protect against poison ivy, clients can apply bentoquatam 5% to the skin 15 minutes prior to exposure and at least every 4 hours as long as risk of exposure continues. The cream forms a protective layer on top of the skin. Calamine lotion can be used for the itching related to poison ivy exposure. Vinegar and water is not an effective way to manage the prevention of poison ivy. Benadryl will not protect against poison ivy.
A client is scheduled for diagnostic skin testing in 1 week. What should the nurse be sure to instruct the client prior to the scheduled appointment?
- A. Do not take prescribed or over-the-counter antihistamines or cold preparations for at least 72 hours before testing.
- B. Do not take antihypertensive medications the morning of the scheduled skin testing.
- C. Do not take non steroidal anti-inflammatory (NSAID) medications for 1 week prior to the scheduled skin testing.
- D. Prior to having the skin test, have the client take an over-the-counter histamine prophylactically for any possible reaction that could cause anaphylaxis.
Correct Answer: A
Rationale: The nurse instructs clients who are scheduled for diagnostic skin testing to avoid taking prescribed or over-the-counter antihistamines or cold preparations for at least 48 to 72 hours before testing. Doing so reduces the potential for false-negative results. Clients must temporarily discontinue some medications for even longer. Antihypertensive medication should not be omitted the day of the procedure. It is not necessary to omit the use of NSAIDs.
The nurse is caring for a client with an autoimmune disease. What is a characteristic of autoimmune disorders?
- A. Progressive tissue damage without any verifiable etiology
- B. Absence of a triggering event
- C. Profound fatigue with no identifiable cause
- D. Affects only older adults and infants less than 3 months
Correct Answer: A
Rationale: Diseases are considered autoimmune disorders and are characterized by unrelenting, progressive tissue damage without any verifiable etiology. In many autoimmune disorders, there tends to be a triggering event, such as an infection, trauma, or introduction of a drug that integrates itself into the membranes of the host's cells. Although older adults face a greater risk of developing autoimmune disorders, persons belonging to any age-group can be affected. Chronic fatigue syndrome is primarily characterized by profound fatigue with no identifiable cause, and this is not a characteristic of autoimmune disorders.
A client is taking a corticosteroid for the treatment of systemic lupus erythematosus. When the nurse is providing instructions about the medication to the client, what priority information should be included?
- A. If the client experiences nausea, omit the dose.
- B. The client should be alert for joint aches.
- C. This medication is commonly used for many inflammatory reactions and is relatively safe.
- D. Be alert for signs and symptoms of infection and report them immediately to the physician.
Correct Answer: D
Rationale: Instruct the client about signs and symptoms of and the increased risk for infection. Instruct the client to report signs and symptoms of infection immediately to the physician. Early treatment promotes a shorter duration of illness and reduced complication. Tell the client to avoid high-risk activities, such as being in crowds, during periods of immunosuppression. The client should not omit a dose if nausea is experienced but instead may take the medication with food. There are many side effects and required laboratory work to detect the side effects from immunosuppressive therapy. Joint aches are vague symptoms and are not a priority for reporting purposes.