Nokea
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.
You may also like to solve these questions
The nurse encourages a new mother to breastfeed her infant, even for a short time, because colostrum will provide the infant with which of the following types of immunity?
- A. Innate
- B. Active
- C. Passive
- D. Cell-mediated
Correct Answer: C
Rationale: Colostrum provides passive immunity through antibodies from the mother; these antibodies protect the infant for a few months. However, memory cells are not retained, so the protection is not permanent. Innate immunity is present at birth and occurs without exposure to an antigen. Active immunity requires that the infant manufacture antibodies after exposure to an antigen. Cell-mediated immunity is acquired through T-lymphocytes and is a form of active immunity.
A patient diagnosed with systemic lupus erythematosus (SLE) is scheduled for plasmapheresis. Which of the following pathophysiological events should the nurse plan to teach the patient about this procedure?
- A. It eliminates eosinophils and basophils from blood
- B. It removes antibody-antigen complexes from circulation
- C. It prevents foreign antibodies from damaging various body tissues.
- D. It decreases the damage to organs caused by attacking T-lymphocytes.
Correct Answer: B
Rationale: Plasmapheresis is used in SLE to remove antibodies, antibody-antigen complexes, and complement from blood. T-lymphocytes, foreign antibodies, eosinophils, and basophils do not contribute to the tissue damage in SLE.
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.
The nurse is caring for a patient who is receiving an IV antibiotic and develops wheezes and dyspnea. In which order should the nurse implement these prescribed actions?
- A. Discontinue the antibiotic infusion.
- B. Give diphenhydramine IV.
- C. Inject epinephrine IM.
- D. Start 100% oxygen using a nonrebreather mask.
Correct Answer: A,D,C,B
Rationale: The nurse should initially discontinue the antibiotic, since it is the likely cause of the allergic reaction. Next, oxygen delivery should be maximized, followed by treatment of bronchoconstriction with epinephrine administered IM or IV. Diphenhydramine will work more slowly than epinephrine, but will help prevent progression of the reaction.
The nurse is caring for a patient who has experienced Goodpasture's syndrome. Which of the following adverse effects should the nurse be aware of?
- A. Thrombocytopenia
- B. Leukopenia
- C. Angioedema
- D. Pulmonary hemorrhage
Correct Answer: D
Rationale: Goodpasture's syndrome is a rare disorder involving the lungs and the kidneys. An antibody-mediated autoimmune reaction occurs involving the glomerular and alveolar basement membranes. The circulating antibodies combine with tissue antigen to activate the complement system which causes deposits of IgG to form along the basement membranes of the lungs or the kidneys. This reaction may result in pulmonary hemorrhage and glomerulonephritis.