Quiz Answers
Case Scenario/Description
Location: Medical
Unit Time: 11:00
Situation:
The patient is Kenneth Bronson, a 27-year-old male who just arrived
at the Medical Unit from the Emergency Department with the
diagnosis of right lower lobe pneumonia confirmed by chest x-ray.
Background:
He presented to the Emergency Department 2 hours ago with chest
tightness and difficulty breathing in addition to the productive
cough, fever, and fatigue he's had for about a week. He has a
history of smoking for 10 years.
Assessment:
He was given acetaminophen 650 mg orally in the Emergency
Department for a temperature of 102.6 °F (39.2 °C). Heart rate has
been in the 80s, respiratory rate is 24, and blood pressure is 132/80
at the right arm. SpO2 on room air was 90%, which increased to 93%
with supplemental oxygen 2 L per nasal cannula. He has a 20-gauge
IV in the left hand with normal saline infusing at 75 mL/hr.
Recommendation:
Provider's orders and lab results are available in the chart for you to
view. Pharmacy just delivered the IV antibiotic that needs to be
given and will bring the oral antibiotic within the next hour.
1
The nurse recognizes the clinical manifestations of
anaphylaxis when the client exhibits which of the
following signs and symptoms? (Select all that apply.)
Your Response: Bronchospasm,
Severe dyspnea,
Abrupt onset
Rationale:An anaphylactic reaction produces a clinical syndrome with an abrupt onset that
affects multiple organ systems. It is a systemic reaction as opposed to a local reaction. Classic
initial symptoms are bronchospasm (which manifests as severe dyspnea) and hypotension.
Temperature was preexisting with pneumonia, as were decreased breath sounds. Wheezes are
often heard during an anaphylactic reaction due to narrowed airways. On the other hand, rhonchi
are most often heard due to blockage of the main airways by mucus secretions, which could
occur with pneumonia.
Remediation:
Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th Edition, p. 1046
2
, After initial identification of potential for anaphylaxis,
the nurse's priority assessment is
followed Choose Answer..
by
Choose Answer..
.
Your Response:auscultate lungs, assess blood pressure
Rationale:When a client is in respiratory distress, it is important to determine the cause so that
appropriate measures to treat the client can be started. Assessing the airway, breathing, and
circulation are the basic first steps. Auscultating the lungs helps to further delineate what the
potential cause and treatment will be. It is essential to assess blood pressure immediately after
airway; due to increased vascular permeability, subsequent decrease in peripheral resistance, and
leakage of plasma fluids, hypotension is a serious secondary threat that could lead to shock.
Remediation:
Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th Edition, p. 1047
3
Which of the following agents are responsible for causing
the most serious anaphylactic reactions? (Select all that
apply.)
Your Response: Antibiotic medications,
Radiocontrast agents
Rationale:Antibiotics and radiocontrast agents have the most serious significant reactions. All
of the answer choices are common causes of anaphylaxis. Penicillin is the most common
medication to cause anaphylaxis, and antibiotics and radiocontrast agents cause the most serious
anaphylactic reactions.
Remediation:
Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th Edition, p. 1047
4
Which of the following discharge instructions would be
most important for the nurse to provide to a client who
has experienced an anaphylactic reaction? (Select all
that apply.)
Your Response: Obtain and always wear a medical alert bracelet for
penicillin.,
Obtain and always carry an auto-injectable epinephrine device.
Rationale:All clients who have had an anaphylactic reaction should receive a prescription for an
auto-injectable epinephrine device, and they should carry that device at all times. People who
are predisposed to anaphylaxis should wear medical identification (e.g., a necklace or bracelet)
that identifies the allergies. Genetic testing would not be applicable in this case, because it is
Case Scenario/Description
Location: Medical
Unit Time: 11:00
Situation:
The patient is Kenneth Bronson, a 27-year-old male who just arrived
at the Medical Unit from the Emergency Department with the
diagnosis of right lower lobe pneumonia confirmed by chest x-ray.
Background:
He presented to the Emergency Department 2 hours ago with chest
tightness and difficulty breathing in addition to the productive
cough, fever, and fatigue he's had for about a week. He has a
history of smoking for 10 years.
Assessment:
He was given acetaminophen 650 mg orally in the Emergency
Department for a temperature of 102.6 °F (39.2 °C). Heart rate has
been in the 80s, respiratory rate is 24, and blood pressure is 132/80
at the right arm. SpO2 on room air was 90%, which increased to 93%
with supplemental oxygen 2 L per nasal cannula. He has a 20-gauge
IV in the left hand with normal saline infusing at 75 mL/hr.
Recommendation:
Provider's orders and lab results are available in the chart for you to
view. Pharmacy just delivered the IV antibiotic that needs to be
given and will bring the oral antibiotic within the next hour.
1
The nurse recognizes the clinical manifestations of
anaphylaxis when the client exhibits which of the
following signs and symptoms? (Select all that apply.)
Your Response: Bronchospasm,
Severe dyspnea,
Abrupt onset
Rationale:An anaphylactic reaction produces a clinical syndrome with an abrupt onset that
affects multiple organ systems. It is a systemic reaction as opposed to a local reaction. Classic
initial symptoms are bronchospasm (which manifests as severe dyspnea) and hypotension.
Temperature was preexisting with pneumonia, as were decreased breath sounds. Wheezes are
often heard during an anaphylactic reaction due to narrowed airways. On the other hand, rhonchi
are most often heard due to blockage of the main airways by mucus secretions, which could
occur with pneumonia.
Remediation:
Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th Edition, p. 1046
2
, After initial identification of potential for anaphylaxis,
the nurse's priority assessment is
followed Choose Answer..
by
Choose Answer..
.
Your Response:auscultate lungs, assess blood pressure
Rationale:When a client is in respiratory distress, it is important to determine the cause so that
appropriate measures to treat the client can be started. Assessing the airway, breathing, and
circulation are the basic first steps. Auscultating the lungs helps to further delineate what the
potential cause and treatment will be. It is essential to assess blood pressure immediately after
airway; due to increased vascular permeability, subsequent decrease in peripheral resistance, and
leakage of plasma fluids, hypotension is a serious secondary threat that could lead to shock.
Remediation:
Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th Edition, p. 1047
3
Which of the following agents are responsible for causing
the most serious anaphylactic reactions? (Select all that
apply.)
Your Response: Antibiotic medications,
Radiocontrast agents
Rationale:Antibiotics and radiocontrast agents have the most serious significant reactions. All
of the answer choices are common causes of anaphylaxis. Penicillin is the most common
medication to cause anaphylaxis, and antibiotics and radiocontrast agents cause the most serious
anaphylactic reactions.
Remediation:
Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th Edition, p. 1047
4
Which of the following discharge instructions would be
most important for the nurse to provide to a client who
has experienced an anaphylactic reaction? (Select all
that apply.)
Your Response: Obtain and always wear a medical alert bracelet for
penicillin.,
Obtain and always carry an auto-injectable epinephrine device.
Rationale:All clients who have had an anaphylactic reaction should receive a prescription for an
auto-injectable epinephrine device, and they should carry that device at all times. People who
are predisposed to anaphylaxis should wear medical identification (e.g., a necklace or bracelet)
that identifies the allergies. Genetic testing would not be applicable in this case, because it is
