The nurse asks the patient if she has any allergies. The patient states that she has an allergy
to peanuts, but has not had anything to eat today. The patient also states that she worked
earlier today as a nursing assistant.
ANS: B, C
Which laboratory tests does the nurse anticipate the provider will order? (Select all that
With the CBC with ditterential (ditt), look for increased eosinophils, which may be as high as
apply.)
12% (normal = 1%). Some patients may also have a higher than normal total WBC count.
Normal IgE levels are about 39 IU/mL (<100 IU/mL). This level is greatly increased with
A.Electrolytes
allergies.
B.Immunoglobulin E
C.CBC with ditterential
D.Liver function tests (LFT)
Five minutes later, the patient continues to experience shortness of breath. She states that she
is feeling anxious and frightened. ANSWER: D
What is the appropriate nursing intervention? The patient has swelling of the lips and eyes, indicating angioedema. She is short of breath
and may have abnormal breath sounds such as crackles and wheezes. Respiratory failure due
A.Reassure the patient that all will be well. to swelling of the tongue and larynx may soon follow. Emergency respiratory management is
B.Prepare the patient for a stat chest x-ray. critical during an anaphylactic reaction because severity increases with time. This is the time
C.Ask the provider to prescribe an antianxiety drug. to call the Rapid Response Team to establish and stabilize the patient's airway.
D.Assess the patient for signs of respiratory distress.
What therapies does the nurse anticipate the provider will order? (Select all that apply.) ANSWER: A, B, D, E
A. Epinephrine (Adrenalin) If the reaction is severe, the provider may order the first-line drug epinephrine (Adrenalin)
B.Diphenhydramine (Benadryl) for the patient. Antihistamines such as diphenhydramine (Benadryl) are second-line drugs
C.Acetaminophen (Tylenol) and are usually given for angioedema and urticaria. Acetaminophen (Tylenol) would not be
D.IV fluids indicated. IV fluids are usually started when a reaction is suspected, and the provider may
E.Oxygen order oxygen to address the patient's shortness of breath.
What is the best statement to describe a nurse who develops a contact dermatitis from • Answer: D
wearing latex gloves? • Rationale: Two types of latex allergies can occur: A type IV allergic contact dermatitis that is
1. Is demonstrating an allergy to natural latex proteins caused by chemicals used in the manufacturing process of latex gloves and a type 1 allergic
2. Can use powder-free latex gloves to prevent the development of symptoms reaction that is a response to the natural rubber proteins occurs within minutes of contact
3. Should use an oil-based hand cream when wearing gloves to prevent latex allergy. with the proteins and may manifest with reactions ranging from skin redness to full blown
4. Has a type IV allergic reaction to chemicals used in the manufacturing of latex gloves anaphylactic shock.
The nurse has educated the patient with a shellfish allergy about signs and symptoms of
angioedema. Which patient statement requires further nursing education? ANS: A
Shrimp is a shellfish, and should not be consumed by patients with shellfish allergies. This
A. "I can eat shrimp because it is not a shellfish." statement therefore requires further teaching by the nurse. The patient should carry an
B. "There is an epinephrine injector in my purse at all times." epinephrine injector at all times. Symptoms of angioedema include swelling of eyes, lips, and
C."Symptoms of angioedema include swelling of eyes, lips, and tongue." tongue. Patients should report all allergies to health care providers.
D."When I see a new physician, I will report that I have a shellfish allergy."
A patient has been admitted to the ED with bilateral eyelid swelling and subsequent diflculty ANS: A
seeing. What is the priority nursing assessment?
The patient likely has angioedema that has caused the swelling. This can progress very quickly
A.Airway to attect the airway. Interventions focus on stopping the reaction and ensuring an adequate
B. Nasal cavity airway. While swelling can invade the nasal cavity and is likely caused by a home medication,
C. Home medications the priority is on securing and maintaining the airway. A history of visual disturbances is
D. History of visual disturbances unrelated as vision will likely return when eyelid swelling is decreased.
A nurse is administering a new medication intravenously to a patient. The patient becomes
short of breath and begins to experience itching and hives. What is the priority nursing
response?
1/2
to peanuts, but has not had anything to eat today. The patient also states that she worked
earlier today as a nursing assistant.
ANS: B, C
Which laboratory tests does the nurse anticipate the provider will order? (Select all that
With the CBC with ditterential (ditt), look for increased eosinophils, which may be as high as
apply.)
12% (normal = 1%). Some patients may also have a higher than normal total WBC count.
Normal IgE levels are about 39 IU/mL (<100 IU/mL). This level is greatly increased with
A.Electrolytes
allergies.
B.Immunoglobulin E
C.CBC with ditterential
D.Liver function tests (LFT)
Five minutes later, the patient continues to experience shortness of breath. She states that she
is feeling anxious and frightened. ANSWER: D
What is the appropriate nursing intervention? The patient has swelling of the lips and eyes, indicating angioedema. She is short of breath
and may have abnormal breath sounds such as crackles and wheezes. Respiratory failure due
A.Reassure the patient that all will be well. to swelling of the tongue and larynx may soon follow. Emergency respiratory management is
B.Prepare the patient for a stat chest x-ray. critical during an anaphylactic reaction because severity increases with time. This is the time
C.Ask the provider to prescribe an antianxiety drug. to call the Rapid Response Team to establish and stabilize the patient's airway.
D.Assess the patient for signs of respiratory distress.
What therapies does the nurse anticipate the provider will order? (Select all that apply.) ANSWER: A, B, D, E
A. Epinephrine (Adrenalin) If the reaction is severe, the provider may order the first-line drug epinephrine (Adrenalin)
B.Diphenhydramine (Benadryl) for the patient. Antihistamines such as diphenhydramine (Benadryl) are second-line drugs
C.Acetaminophen (Tylenol) and are usually given for angioedema and urticaria. Acetaminophen (Tylenol) would not be
D.IV fluids indicated. IV fluids are usually started when a reaction is suspected, and the provider may
E.Oxygen order oxygen to address the patient's shortness of breath.
What is the best statement to describe a nurse who develops a contact dermatitis from • Answer: D
wearing latex gloves? • Rationale: Two types of latex allergies can occur: A type IV allergic contact dermatitis that is
1. Is demonstrating an allergy to natural latex proteins caused by chemicals used in the manufacturing process of latex gloves and a type 1 allergic
2. Can use powder-free latex gloves to prevent the development of symptoms reaction that is a response to the natural rubber proteins occurs within minutes of contact
3. Should use an oil-based hand cream when wearing gloves to prevent latex allergy. with the proteins and may manifest with reactions ranging from skin redness to full blown
4. Has a type IV allergic reaction to chemicals used in the manufacturing of latex gloves anaphylactic shock.
The nurse has educated the patient with a shellfish allergy about signs and symptoms of
angioedema. Which patient statement requires further nursing education? ANS: A
Shrimp is a shellfish, and should not be consumed by patients with shellfish allergies. This
A. "I can eat shrimp because it is not a shellfish." statement therefore requires further teaching by the nurse. The patient should carry an
B. "There is an epinephrine injector in my purse at all times." epinephrine injector at all times. Symptoms of angioedema include swelling of eyes, lips, and
C."Symptoms of angioedema include swelling of eyes, lips, and tongue." tongue. Patients should report all allergies to health care providers.
D."When I see a new physician, I will report that I have a shellfish allergy."
A patient has been admitted to the ED with bilateral eyelid swelling and subsequent diflculty ANS: A
seeing. What is the priority nursing assessment?
The patient likely has angioedema that has caused the swelling. This can progress very quickly
A.Airway to attect the airway. Interventions focus on stopping the reaction and ensuring an adequate
B. Nasal cavity airway. While swelling can invade the nasal cavity and is likely caused by a home medication,
C. Home medications the priority is on securing and maintaining the airway. A history of visual disturbances is
D. History of visual disturbances unrelated as vision will likely return when eyelid swelling is decreased.
A nurse is administering a new medication intravenously to a patient. The patient becomes
short of breath and begins to experience itching and hives. What is the priority nursing
response?
1/2
