Question 1

Which is the priority nursing action to decrease the risk of a transfusion reaction?

Accepted Answer

D

Question 2

The nurse is assessing a patient who is receiving intravenous (IV)antibiotics.Which item in the patient's health history increases the risk for experiencing a hypersensitivity reaction?

Accepted Answer

Previous antibiotic therapy can increase the risk of hypersensitivity reaction to antibiotics. Age, race, and concurrent chronic illness do not have a direct correlation with hypersensitivity reactions to antibiotics.

Question 3

The nurse is providing care to a patient with lupus.Which medication should the nurse prepare to teach this patient about based on the diagnosis?

Accepted Answer

Azathioprine, cyclosporine, and mycophenolate mofetil are immunosuppressants used to treat lupus. Epinephrine is not used to treat lupus.

Question 4

The nurse is caring for a patient with a history of latex allergies.The patient develops audible wheezing,pruritus,urticaria,and signs of angioedema.Which is the priority intervention for this patient?

Accepted Answer

The patient is experiencing signs of an anaphylactic reaction, which is a medical emergency. The priority intervention is to administer epinephrine 1:1,000 by subcutaneous injection per the healthcare provider's orders. Option A is important but not the priority intervention in this case. Option B can be administered after epinephrine injection. Option D can be done later but is not the priority intervention at this time.

Question 5

The nurse is admitting a pediatric patient to the hospital with a ventroperitoneal (VP)shunt malfunction.The patient's family speaks very little English.The interpreter has arrived and the nurse is obtaining a health history from the parents and learns that the patient received the shunt at birth after a menigocele repair.Based on this data,which product should be avoided when providing care to this patient?

Accepted Answer

Based on the patient history of having a VP shunt, the nurse should avoid latex gloves as the patient may have a latex allergy.

Question 6

A nurse has been providing a young adult patient with a history of hypersensitivity reactions.The nurse is preparing instructions on the correct methods for using an EpiPen.Which patient statement indicates understanding of the proper technique?

Accepted Answer

The correct technique for using an EpiPen includes ensuring that it is always available, as it needs to be administered as quickly as possible in the event of a hypersensitivity reaction. Choice A indicates understanding of this important point. Choices B, C, and D are incorrect or inappropriate.

Question 7

The nurse is caring for a patient in an allergy clinic.After completing the patient history,the nurse selects the nursing diagnosis of Risk for Shock.Which item in the patient's history supports the need for this nursing diagnosis?

Accepted Answer

A history of an anaphylactic reaction to shellfish indicates a potential for a severe allergic reaction, which can lead to anaphylactic shock.

Question 8

Which general manifestation should the nurse anticipate when providing care to a patient diagnosed with DiGeorge's syndrome?

Accepted Answer

Failure to thrive is a common manifestation in patients with DiGeorge's syndrome due to feeding difficulties and poor nutrient absorption. While poor muscle tone, shortness of breath, and delayed development can occur in some cases, they are not the most common or specific manifestations of this condition.

Question 9

Which respiratory data should the nurse anticipate when assessing a patient diagnosed with X-linked agammaglobulinemia (XLA)?

Accepted Answer

Patients with X-linked agammaglobulinemia (XLA) are prone to recurrent respiratory infections due to their compromised immune system, which can lead to tachypnea as the body attempts to compensate for impaired gas exchange.

Question 10

The nurse is caring for a patient who is experiencing anaphylactic shock following the administration of a medication.Which position is the most appropriate for the nurse to place the patient based on this data?

Accepted Answer

The high Fowler position is the most appropriate position for a patient experiencing anaphylactic shock as it allows for maximum expansion of the chest and airway, promoting oxygenation and ventilation. The Trendelenburg position is not recommended as it can increase the risk of hypotension and compromise cardiac output. Flat with legs slightly elevated and supine positions do not provide adequate respiratory support for a patient in anaphylactic shock.

Question 11

A pediatric patient with a history of anaphylactic hypersensitivity reactions will be discharged with a prescription for an EpiPen.Which statement is appropriate for the nurse to include in the discharge instructions for this patient and family?

Accepted Answer

It is important to frequently check the expiration date of the EpiPen as it can lose its effectiveness over time. This ensures that the medication will work when needed in case of an anaphylactic hypersensitivity reaction. Keeping the medication in one location that is easy to remember is also helpful, but not as critical as checking the expiration date or keeping it in the car at all times. It is also important to note that EpiPens come prefilled and should not be measured by the patient or family.

Question 12

The nurse is providing care to a patient with psoriasis.Which medication should the nurse prepare to teach this patient about based on the diagnosis?

Accepted Answer

Cyclosporine is often prescribed for the treatment of moderate to severe psoriasis by suppressing the immune response that causes the skin inflammation. Epinephrine is a medication for emergency situations such as severe allergic reactions. Azathioprine and mycophenolate mofetil are immunosuppressive medications, but they are not commonly used for the treatment of psoriasis.

Question 13

Which is the priority nursing diagnosis for a patient diagnosed with X-linked agammaglobulinemia (XLA)?

Accepted Answer

Patients with XLA have a deficiency in immunoglobulins, making them highly susceptible to infections. Therefore, the priority nursing diagnosis would be the risk for infection. The other options are not directly related to the patient's diagnosis and management.

Question 14

The nurse is preparing to assess a patient when one of the patient's family members begins showing symptoms of a latex sensitivity.Which action by the nurse is the most appropriate?

Accepted Answer

The most appropriate action by the nurse is to obtain latex-free products for the patient's room to prevent any further exposure to the family member who is showing symptoms of a latex sensitivity. Asking the family member to leave the unit may not be suitable as they may be there to support the patient, and transferring the patient may not be necessary if latex-free products are available. Waiting until Monday to report the problem to the supervisor is not appropriate as it could potentially cause harm to the family member and other patients in the meantime.

Question 15

The nurse suspects that the patient is experiencing a reaction to a specific antigen.Which laboratory result supports the conclusion made by the nurse?

Accepted Answer

A patch test with a 1-inch area of erythema indicates a positive allergic reaction to a specific antigen. The other laboratory results do not necessarily indicate an allergic reaction.

Question 16

The nurse is providing care to a patient with autoimmune hepatitis.Which medication should the nurse prepare to teach this patient about based on the diagnosis?

Accepted Answer

Azathioprine is an immunosuppressive medication commonly used in the treatment of autoimmune hepatitis. It works by suppressing the immune system, which reduces inflammation in the liver and helps to prevent further liver damage. Epinephrine, cyclosporine, and mycophenolate mofetil are not typically used in the treatment of autoimmune hepatitis. Epinephrine is a medication used for emergency treatment of severe allergic reactions, cyclosporine is used to prevent organ rejection after a transplant, and mycophenolate mofetil is used to prevent rejection of transplanted organs or treat autoimmune disorders such as lupus.

Question 17

The nurse is providing care for a patient diagnosed with agammaglobulinemia.Which is the anticipated treatment for this patient?

Accepted Answer

Agammaglobulinemia is a rare condition characterized by the absence or severe reduction of all classes of immunoglobulins, resulting in recurrent bacterial infections. The best treatment for this patient would be IVIG. This is a treatment that provides the patient with immunoglobulins from donated blood plasma to help boost their immune system and fight off infections. Oral diphenhydramine is used to treat allergic reactions, topical corticosteroids are used to treat skin inflammation, and subcutaneous epinephrine is used for severe allergic reactions. However, none of these treatments address the underlying issue of agammaglobulinemia.

Question 18

A nurse is caring for a patient with seasonal hypersensitivity reactions.What teaching would the nurse provide to improve this patient's comfort?

Accepted Answer

The answer of A nurse is caring for a patient...

Question 19

The nurse is providing care to a patient diagnosed with X-linked agammaglobulinemia (XLA).Which should the nurse include in the patient's plan of care?

Accepted Answer

Patients with X-linked agammaglobulinemia (XLA) can receive inactivated vaccines like IPV, as they do not have live components that could pose a risk to immunocompromised individuals.

Question 20

A nurse is caring for a pediatric patient who is receiving an infusion of intravenous antibiotic at the ambulatory clinic.Which clinical manifestation indicates that the patient is experiencing a type I hypersensitivity reaction?

Accepted Answer

Hypotension is a common symptom of anaphylaxis, which is a severe type I hypersensitivity reaction. Erythema, fever, and joint pain are not specific to type I hypersensitivity reactions.

Quiz 20: Coordinating Care for Patients With Immune Disorders