Nokea
The patient who had an asthma-like reaction to a desensitization shot was medicated with a subcutaneous injection of epinephrine. For which effect will the nurse assure the anxious patient this will have?
- A. Cause vasodilation.
- B. Produce bronchodilation.
- C. Cause productive coughing.
- D. Reduction of pulse rate.
Correct Answer: B
Rationale: The drug epinephrine is given in the case of anaphylaxis because it is a quick-acting drug that produces bronchodilation and vasoconstriction, which relieves respiratory distress. The drug can be ordered to be repeated every 20 minutes. The patient may experience an increase in heart rate.
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The nurse arrives at the bedside of a patient who has had a unit of packed cells infusing in his right arm for 35 minutes. He is complaining of chills, itching, and shortness of breath. What will be the nurse's initial action?
- A. Cover with a warm blanket.
- B. Take the patient's temperature.
- C. Elevate the head of the bed.
- D. Stop the transfusion and continue with saline.
Correct Answer: D
Rationale: Moderate reactions, resulting in fever, chills, urticaria, and wheezing, occur after the first 30 minutes of administration. In the event of a moderate reaction, stop the transfusion, continue with saline, and notify the health care provider. Elevation of the head, taking vital signs, and covering with a warm blanket are not wrong, but are not of primary importance.
In which patient will the nurse be most concerned about immunodeficiency disorder?
- A. The patient taking desensitization injections (immunotherapy)
- B. The patient on long-term radiation therapy for cancer
- C. The overweight patient
- D. The patient recently diagnosed with lupus erythematosus
Correct Answer: B
Rationale: Radiation destroys lymphocytes and depletes the stem cells. Prolonged radiation depresses the bone marrow.
The nurse explains that when the patient received tetanus antitoxin with the antibodies in it, the patient received which type of immunity?
- A. active natural
- B. passive natural
- C. active artificial
- D. passive artificial
Correct Answer: D
Rationale: When a person receives an inoculation of antibodies from another source, as with tetanus antitoxin, it is considered a passive artificial immunity.
The nurse takes into consideration that when the antigen and antibody react, the complement system is activated. This results in which activity?
- A. toughens the cell wall.
- B. generates more T cells.
- C. attracts phagocytes.
- D. makes the antigen resistant.
Correct Answer: C
Rationale: The complement system is a group of plasma proteins that are dormant until there is an antigen-antibody interaction. The proteins destroy the cell membrane and attract phagocytes.
A type IV latex allergy is characterized by ___
Correct Answer: contact dermatitis
Rationale: Type IV latex allergy is that of a contact dermatitis.