Nokea
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.
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Which of the following adverse reactions should the nurse monitor when a patient is undergoing plasmapheresis?
- A. Shortness of breath
- B. High blood pressure
- C. Transfusion reactions
- D. Hypotension and paresthesia
Correct Answer: D
Rationale: Hypotension and paresthesia may occur as the result of plasmapheresis. Citrate is used as an anticoagulant and may cause hypocalcemia, which may manifest as headache, paresthesias, and dizziness. The other clinical manifestations are not associated with plasmapheresis.
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.
The nurse is admitting a patient to hospital who has acute rejection of an organ transplant. Which of the following patients is the most appropriate roommate?
- A. A patient who has viral pneumonia
- B. A patient with second-degree burns
- C. A patient who is recovering from an anaphylactic reaction to a bee sting
- D. A patient with graft-versus-host disease after a recent bone marrow transplant
Correct Answer: C
Rationale: Treatment for a patient with acute rejection includes administration of additional immunosuppressants, and the patient should not be exposed to increased risk for infection as would occur from patients with viral pneumonia, graft-versus-host disease, and burns. There is no increased exposure to infection from a patient with anaphylaxis.
Which of the following adverse effects is related to cyclosporine administration?
- A. Nephrotoxicity
- B. Aseptic necrosis
- C. Peptic ulcer
- D. Leukopenia
Correct Answer: A
Rationale: Nephrotoxicity is the most severe adverse effect of cyclosporine. Aseptic necrosis, peptic ulcer, and leukopenia are all adverse effects of the use of corticosteroids, for example, prednisone.
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.