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Which action will the nurse take when a patient is receiving increasing strength of the dose in the injections for immunotherapy?
- A. Observe the patient for at least 20 minutes after administration.
- B. Take the vital signs every 10 minutes for an hour.
- C. Have the patient lie down quietly for an hour.
- D. Place a warm compress on the area to speed its absorption.
Correct Answer: A
Rationale: The patient should be observed for 20 minutes after the increased dose of the allergen. If anaphylaxis is going to occur, it will do so within that time frame.
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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.
The nurse recommends to the busy parent of three young children that the antihistamine fexofenadine would be more beneficial than diphenhydramine because fexofenadine has which quality?
- A. is inexpensive.
- B. contains a stimulant for an energy boost.
- C. does not dry out the mucous membranes.
- D. does not induce drowsiness.
Correct Answer: D
Rationale: Allegra does not induce drowsiness as does Benadryl.
In which time frame must blood be transfused within once it has been removed from refrigeration?
- A. 2 hours
- B. 4 hours
- C. 6 hours
- D. 3 hours
Correct Answer: B
Rationale: Blood must be administered within 4 hours after removal from refrigeration, and blood components within 6 hours of removal.
For which purpose is plasmapheresis used in the treatment of rheumatoid arthritis?
- A. To add corticosteroids to relieve pain.
- B. To remove pathologic substances present in the plasma.
- C. To remove waste products such as urea and albumin.
- D. To add antinuclear antibodies
Correct Answer: B
Rationale: Plasmapheresis is the removal of plasma-containing components causing or thought to cause disease.
Which person is most at risk for having a reduced number of T-cells?
- A. 26 year old receiving a second desensitization injection
- B. 35 year old starting back on birth control tablets
- C. The 52 year old started on a new series of Pyridium for cystitis
- D. The 84 year old receiving penicillin for an annually recurring respiratory infection
Correct Answer: D
Rationale: The 84 year old with the deteriorated immune system is at risk for having a reduced number of T-cells.