Question 1

What precautionary safety measure should the nurse take for a patient who is receiving first-time intradermal injections for allergy testing?

Accepted Answer

The patient must always be observed for at least 20 minutes after administration, because hypersensitivity reaction or anaphylaxis may occur.

Question 2

A patient, age 42, develops a severe angioedema involving her face, hands, and feet, with burning and stinging of the lesions. During the assessment, which significant risk factor for allergies does the nurse recognize?

Accepted Answer

A thorough history is the most important diagnostic tool. There is a genetic link to both well-developed immune systems and poorly developed or compromised immune systems.

Question 3

A 72-year-old female patient is admitted with a diagnosis of immunodeficiency disease. The primary nursing goal would be to

Accepted Answer

Unusually severe infections with complications or incomplete clearing of an infection may also indicate an underlying immunodeficiency.

Question 4

A cancer patient who has been receiving cytotoxic drugs has been having frequent sinus infections. During planning of his care, the nurse must remember that this frequency of infections is an indication of possible

Accepted Answer

Drug-induced immunosuppression is the most common type of secondary immunodeficiency disorder. Immunosuppression is a serious side effect of cytotoxic drugs used in cancer chemotherapy.

Question 5

A patient is undergoing immunotherapy on a perennial basis. With this form of treatment, she receives

Accepted Answer

Perennial therapy is most widely accepted, because it allows for a higher cumulative dose, which produces a better effect. Perennial therapy usually begins with 0.05 mL of 1:10,000 dilution and increases to 0.5 mL in a 6-week period.

Question 6

The delayed major process that leads to organ transplant rejection is

Accepted Answer

Delayed hypersensitivity reactions occurring 24 to 72 hours after exposure are mediated by T cells accompanied by release of lymphokines. Tissue transplant rejection is another example.

Question 7

A patient, age 47, is undergoing skin testing with intracutaneous injections on the forearm to identify allergens to which she is sensitive. Immediately after the nurse administers one of the injections, the patient complains of itching at the site, weakness, and dizziness. Which action by the nurse is most appropriate initially?

Accepted Answer

At the first sign of reaction, 0.2 to 0.5 mL of epinephrine 1:1,000 is given subcutaneously.

Question 8

A patient, age 28, is treated at the clinic with an injection of long-acting penicillin for a streptococcal throat infection. Her history reveals that she has received penicillin before with no allergic responses. When the penicillin injection is administered, which information should be given to the patient by the nurse?

Accepted Answer

The patient must always be observed for at least 20 minutes after administration, because hypersensitivity reaction or anaphylaxis may occur.

Question 9

A patient with rheumatoid arthritis is scheduled for plasmapheresis. She asks the nurse why they are going to do this procedure. In forming an answer the nurse must remember that the purpose of plasmapheresis is to

Accepted Answer

Plasmapheresis is the removal of plasma-containing components causing or thought to cause disease.

Question 10

A patient comes to the emergency department with dyspnea, wheezing, and urticaria over the arms and face after being stung by a bee. The nurse would begin immediate care for this patient because he or she is having a(n)

Accepted Answer

Fatal reactions are associated with a fall in blood pressure, laryngeal edema, and bronchospasm, leading to cardiovascular collapse, myocardial infarction, and respiratory failure. Early recognition of signs and symptoms and early treatment may prevent severe reactions and even death.

Question 11

A patient is recovering from a kidney transplant. He is receiving cyclosporine after surgery. The purpose of this drug is to

Accepted Answer

Tissue reaction does not occur immediately after transplantation. It takes several days for vascularization to occur. Seven to ten days after blood supply is adequately established, sensitized lymphocytes appear in sufficient numbers for sloughing to occur at the site. Graft rejection is slowed through the use of chemical agents that interfere with the immune response process.

Question 12

A patient has been admitted with pernicious anemia and has asked the nurse to tell him what type of disorder pernicious anemia is. The nurse tells him that it is an immune disorder that results from failures of the tolerance to one's "self." Responding immunologically to one's own antigens is called a(n)

Accepted Answer

Autoimmune disorders are failures of the tolerance to "self." Autoimmune disorders may be described as an immune attack on the self and result from the failure to distinguish "self" protein from "foreign" protein.

Question 13

During a patient history, the nurse notices that the patient has had five upper respiratory infections in the past 18 months. The nurse begins to suspect that the patient may have an immunodeficiency disease because the first evidence of this disease is

Accepted Answer

The first evidence of immunodeficiency disease (an abnormal condition of the immune system in which cellular or humoral immunity is inadequate and resistance to infection is decreased) is an increased susceptibility to infection.

Question 14

A patient comes to the clinic for his weekly "allergy shot." He missed his appointment the week before because of a family emergency. Which action by the nurse is appropriate in administering his injection?

Accepted Answer

Interrupted regimens may place the patient at risk for reaction.

Question 15

A patient has a history of allergic reactions to bee stings. Which actions should the nurse teach to avoid an anaphylactic reaction to bee stings?

Accepted Answer

Teach the patient avoidance of allergens.

Question 16

A patient who has suffered an allergic reaction to a bee sting is stabilized and prepared for discharge from the clinic. During discussion of prevention and management of further allergic reactions, the nurse identifies a need for additional teaching based on which comment?

Accepted Answer

The nurse's responsibilities in patient education are as follows: Teach the patient preparation and administration of epinephrine subcutaneously. There is no need for the patient to take maintenance dosages of corticosteroids because this was a short, rapid reaction.

Question 17

The correct nursing intervention for anaphylaxis would be

Accepted Answer

Anaphylaxis-If moderate to severe signs and symptoms occur, IV therapy may be initiated to prevent vascular collapse and the patient may be intubated to prevent airway obstruction. Nursing interventions and patient teaching-Assess respiratory status, including dyspnea, wheezing, and decreased breath sounds.

Question 18

A liver transplant patient is receiving azathioprine (Imuran). What nursing goal is critical for this patient?

Accepted Answer

Graft rejection is slowed through the use of chemical agents that interfere with the immune response process. Included are corticosteroids, cyclosporine (Neoral, Sandimmune), and azathioprine (Imuran). This chemical therapy is referred to as immunosuppressive (the administration of agents that significantly interfere with the ability of the immune system to respond to antigenic stimulation by inhibition of cellular and humoral immunity) therapy.

Question 19

After a bee sting, a patient's face becomes edematous and she begins to wheeze. Based on this assessment, the nurse would be prepared to administer:

Accepted Answer