,26/27NUR 201/NUR201 EXAM 4 MEDICAL-SURGICAL
NURSING I |JERSY COLLEGE| Q&A & RATIONALES
1. A nurse is assessing a patient who suddenly develops wheezing, generalized hives,
and hypotension after receiving an IV antibiotic. Which action has the highest
priority?
A) Administer intramuscular epinephrine
B) Apply topical hydrocortisone
C) Obtain a dietary history
D) Encourage oral fluids
Correct Answer: Administer intramuscular epinephrine
Rationale: Wheezing, urticaria, and hypotension indicate anaphylaxis, a rapidly
progressive systemic hypersensitivity reaction involving airway narrowing and circulatory
collapse. Intramuscular epinephrine is the first-line treatment because alpha-adrenergic
effects increase vascular tone and reduce mucosal edema while beta-adrenergic effects
improve bronchodilation and cardiac output. Airway support, oxygen, IV fluids, and
additional medications may also be needed, but they do not replace prompt epinephrine.
2. Which assessment finding is most characteristic of allergic rhinitis?
A) Sneezing, nasal itching, and watery rhinorrhea
B) Purulent sputum with hemoptysis
C) Severe unilateral chest pain
D) Generalized edema
Correct Answer: Sneezing, nasal itching, and watery rhinorrhea
Rationale: Allergic rhinitis is an IgE-mediated inflammatory response to airborne
allergens. Typical manifestations include sneezing, nasal itching, clear rhinorrhea, nasal
congestion, watery or itchy eyes, and sometimes postnasal drainage. Purulent respiratory
secretions and hemoptysis suggest infection or pulmonary disease rather than
uncomplicated allergic rhinitis.
3. Which medication class is commonly used to reduce sneezing and itching associated
with allergic rhinitis?
A) Antihistamines
B) Anticoagulants
C) Loop diuretics
D) Thrombolytics
Correct Answer: Antihistamines
Rationale: Histamine released during an allergic response contributes to itching, sneezing,
rhinorrhea, and ocular symptoms. H1-receptor antihistamines block these effects.
, Intranasal corticosteroids are also highly effective for persistent nasal inflammation and
congestion. Anticoagulants, diuretics, and thrombolytics have no therapeutic role in
allergic rhinitis.
4. A patient with seasonal allergies asks how to reduce exposure to pollen. Which
recommendation is most appropriate?
A) Keep windows closed during high-pollen periods
B) Dry bedding outdoors when pollen counts are high
C) Exercise outside during peak pollen periods
D) Use fans that continuously pull outdoor air inside
Correct Answer: Keep windows closed during high-pollen periods
Rationale: Reducing allergen exposure may decrease symptoms. Keeping windows closed,
using air conditioning or filtration when available, showering after outdoor exposure, and
monitoring pollen counts can help. Outdoor drying of clothing or bedding can collect
pollen and increase exposure.
5. Which patient statement about an epinephrine autoinjector indicates correct
understanding?
A) “I should use it immediately if I develop signs of anaphylaxis.”
B) “I should wait until I lose consciousness.”
C) “I only need it for mild nasal congestion.”
D) “After using it, I never need emergency evaluation.”
Correct Answer: “I should use it immediately if I develop signs of anaphylaxis.”
Rationale: Epinephrine should be administered promptly when anaphylaxis is suspected
because delays increase the risk of respiratory or cardiovascular collapse. Emergency
medical evaluation is still required after use because symptoms may recur or additional
treatment may be necessary. An autoinjector is not intended for isolated mild allergic
rhinitis.
6. Which finding after epinephrine administration for anaphylaxis indicates
improvement?
A) Reduced wheezing and rising blood pressure
B) Increasing stridor
C) Worsening hypotension
D) Progressive cyanosis
Correct Answer: Reduced wheezing and rising blood pressure
Rationale: Improvement in bronchospasm and vascular tone indicates a therapeutic
response to epinephrine. Increasing stridor, cyanosis, or hypotension indicates worsening
airway or circulatory compromise and requires immediate escalation of emergency
treatment.
NURSING I |JERSY COLLEGE| Q&A & RATIONALES
1. A nurse is assessing a patient who suddenly develops wheezing, generalized hives,
and hypotension after receiving an IV antibiotic. Which action has the highest
priority?
A) Administer intramuscular epinephrine
B) Apply topical hydrocortisone
C) Obtain a dietary history
D) Encourage oral fluids
Correct Answer: Administer intramuscular epinephrine
Rationale: Wheezing, urticaria, and hypotension indicate anaphylaxis, a rapidly
progressive systemic hypersensitivity reaction involving airway narrowing and circulatory
collapse. Intramuscular epinephrine is the first-line treatment because alpha-adrenergic
effects increase vascular tone and reduce mucosal edema while beta-adrenergic effects
improve bronchodilation and cardiac output. Airway support, oxygen, IV fluids, and
additional medications may also be needed, but they do not replace prompt epinephrine.
2. Which assessment finding is most characteristic of allergic rhinitis?
A) Sneezing, nasal itching, and watery rhinorrhea
B) Purulent sputum with hemoptysis
C) Severe unilateral chest pain
D) Generalized edema
Correct Answer: Sneezing, nasal itching, and watery rhinorrhea
Rationale: Allergic rhinitis is an IgE-mediated inflammatory response to airborne
allergens. Typical manifestations include sneezing, nasal itching, clear rhinorrhea, nasal
congestion, watery or itchy eyes, and sometimes postnasal drainage. Purulent respiratory
secretions and hemoptysis suggest infection or pulmonary disease rather than
uncomplicated allergic rhinitis.
3. Which medication class is commonly used to reduce sneezing and itching associated
with allergic rhinitis?
A) Antihistamines
B) Anticoagulants
C) Loop diuretics
D) Thrombolytics
Correct Answer: Antihistamines
Rationale: Histamine released during an allergic response contributes to itching, sneezing,
rhinorrhea, and ocular symptoms. H1-receptor antihistamines block these effects.
, Intranasal corticosteroids are also highly effective for persistent nasal inflammation and
congestion. Anticoagulants, diuretics, and thrombolytics have no therapeutic role in
allergic rhinitis.
4. A patient with seasonal allergies asks how to reduce exposure to pollen. Which
recommendation is most appropriate?
A) Keep windows closed during high-pollen periods
B) Dry bedding outdoors when pollen counts are high
C) Exercise outside during peak pollen periods
D) Use fans that continuously pull outdoor air inside
Correct Answer: Keep windows closed during high-pollen periods
Rationale: Reducing allergen exposure may decrease symptoms. Keeping windows closed,
using air conditioning or filtration when available, showering after outdoor exposure, and
monitoring pollen counts can help. Outdoor drying of clothing or bedding can collect
pollen and increase exposure.
5. Which patient statement about an epinephrine autoinjector indicates correct
understanding?
A) “I should use it immediately if I develop signs of anaphylaxis.”
B) “I should wait until I lose consciousness.”
C) “I only need it for mild nasal congestion.”
D) “After using it, I never need emergency evaluation.”
Correct Answer: “I should use it immediately if I develop signs of anaphylaxis.”
Rationale: Epinephrine should be administered promptly when anaphylaxis is suspected
because delays increase the risk of respiratory or cardiovascular collapse. Emergency
medical evaluation is still required after use because symptoms may recur or additional
treatment may be necessary. An autoinjector is not intended for isolated mild allergic
rhinitis.
6. Which finding after epinephrine administration for anaphylaxis indicates
improvement?
A) Reduced wheezing and rising blood pressure
B) Increasing stridor
C) Worsening hypotension
D) Progressive cyanosis
Correct Answer: Reduced wheezing and rising blood pressure
Rationale: Improvement in bronchospasm and vascular tone indicates a therapeutic
response to epinephrine. Increasing stridor, cyanosis, or hypotension indicates worsening
airway or circulatory compromise and requires immediate escalation of emergency
treatment.
