NURSING 265 IMMUNITY WEEK 3 QUESTIONS AND ANSWERS
ELABORATIONS!!
A patient being tested for multiple allergies develops localized redness and
swelling in reaction to a patch skin test. Which intervention by the nurse would
have the highest priority?
Answers :Remove the patch and extract from the skin.
If a severe reaction to a patch skin test occurs, the nurse should immediately
remove the patch and the extract from the skin. Next the nurse should apply a
topical antiinflammatory cream to the site. A subcutaneous injection of epinephrine
may also be necessary.
A patient received penicillin V potassium intramuscular (IM) causing a systemic
anaphylactic reaction. What manifestations does the nurse observe initially?
Answers :Itching and edema
A systemic anaphylactic reaction starts with edema and itching at the site of
exposure to the antigen. Shock can rapidly develop with rapid, weak pulse;
hypotension; dilated pupils; dyspnea; and possible cyanosis. The wheal-and-flare
reaction occurs with a localized anaphylactic reaction such as a mosquito bite.
The nurse is teaching a patient with a latex allergy about preventing and treating
allergic reactions. Which statement, if made by the patient, indicates a need for
further teaching?
Answers :"Because my reactions are not severe, I will not need an EpiPen."
An individual with latex allergies should carry an injectable epinephrine pen. The
proteins in latex are similar to the proteins in certain foods and may cause an
allergic reaction in people who are allergic to latex. Foods to avoid include banana,
avocado, chestnut, kiwi, tomato, water chestnuts, guava, hazelnuts, potatoes,
,peaches, grapes, and apricots. Vinyl gloves are not latex and are safe to use.
Individuals with latex allergies need to share this information with all health care
providers and wear a medical alert bracelet.
The patient with an allergy to bee stings was just stung by a bee. After
administering oxygen, removing the stinger, and administering epinephrine, the
nurse notices the patient is hypotensive. What should be the nurse's first action?
Answers :Place the patient recumbent and elevate the legs.
In this emergency situation, the ABCs (airway, breathing, circulation) are being
followed. For hypotension, the patient should be placed in a recumbent position
with the legs elevated, epinephrine will continue to be administered every 2 to 5
minutes, and fluids will be administered with vasopressors. Diphenhydramine is an
antihistamine used to treat allergy symptoms. Anticipating a tracheostomy may
occur with ongoing patient monitoring. Nitroprusside is a vasodilator and would
not be used now.
A colectomy is scheduled for a patient with ulcerative colitis. The nurse should
plan to include which prescribed measure in the preoperative preparation of this
patient?
Group of answer choices
Answers :Administration of a cleansing enema
What information would have the highest priority for the nurse to include in
preoperative teaching for a patient scheduled for a colectomy?
Answers :How to deep breathe and cough
Because anesthesia, an abdominal incision, and pain can impair the patient's
respiratory status in the postoperative period, it is of high priority to teach the
patient to cough and deep breathe.Otherwise, the patient could develop atelectasis
and pneumonia, which would delay early recovery from surgery and hospital
discharge.
, A colectomy is scheduled for a 38-year-old woman with ulcerative colitis. The
nurse should plan to include what prescribed measure in the preoperative
preparation of this patient?
Answers :Administration of a cleansing enema
RationalePreoperative preparation for bowel surgery typically includes bowel
cleansing with antibiotics, such as oral neomycin, and cleansing enemas, including
Fleet enemas. Instructions to irrigate the colostomy will be done postoperatively. A
clear liquid diet will be used the day before surgery with the bowel cleansing. Oral
antibiotics are given preoperatively and an IV antibiotic may be used in the
operating room.
A patient with severe anaphylactic reaction is experiencing hypovolemic shock.
What physiologic change will help the patient to compensate for the hemodynamic
imbalance?
Answers :
The nurse creates a plan of care for a patient who has had an allergic reaction to a
bee sting. What is the priority expected outcome for this patient?
Answers :This patient is at risk for development of an anaphylactic reaction.
Maintaining a clear and patent airway is a priority outcome with a patient who has
sustained a bee sting and has a known allergy to bees. Comfort and being free of
signs and symptoms of infection are important after ensuring airway patency and
breathing. Although the demonstration of self-administered epinephrine is likely
valuable for the allergic patient, immediately after the bee sting is not the best time
to engage in education because a delay in the administration of epinephrine could
result.Text Reference - p. 214
A patient is diagnosed with a latex allergy after having a reaction to interventions
provided in the acute care facility. Which preventive measures should the nurse
educate the patient about to avoid complications in the future?
ELABORATIONS!!
A patient being tested for multiple allergies develops localized redness and
swelling in reaction to a patch skin test. Which intervention by the nurse would
have the highest priority?
Answers :Remove the patch and extract from the skin.
If a severe reaction to a patch skin test occurs, the nurse should immediately
remove the patch and the extract from the skin. Next the nurse should apply a
topical antiinflammatory cream to the site. A subcutaneous injection of epinephrine
may also be necessary.
A patient received penicillin V potassium intramuscular (IM) causing a systemic
anaphylactic reaction. What manifestations does the nurse observe initially?
Answers :Itching and edema
A systemic anaphylactic reaction starts with edema and itching at the site of
exposure to the antigen. Shock can rapidly develop with rapid, weak pulse;
hypotension; dilated pupils; dyspnea; and possible cyanosis. The wheal-and-flare
reaction occurs with a localized anaphylactic reaction such as a mosquito bite.
The nurse is teaching a patient with a latex allergy about preventing and treating
allergic reactions. Which statement, if made by the patient, indicates a need for
further teaching?
Answers :"Because my reactions are not severe, I will not need an EpiPen."
An individual with latex allergies should carry an injectable epinephrine pen. The
proteins in latex are similar to the proteins in certain foods and may cause an
allergic reaction in people who are allergic to latex. Foods to avoid include banana,
avocado, chestnut, kiwi, tomato, water chestnuts, guava, hazelnuts, potatoes,
,peaches, grapes, and apricots. Vinyl gloves are not latex and are safe to use.
Individuals with latex allergies need to share this information with all health care
providers and wear a medical alert bracelet.
The patient with an allergy to bee stings was just stung by a bee. After
administering oxygen, removing the stinger, and administering epinephrine, the
nurse notices the patient is hypotensive. What should be the nurse's first action?
Answers :Place the patient recumbent and elevate the legs.
In this emergency situation, the ABCs (airway, breathing, circulation) are being
followed. For hypotension, the patient should be placed in a recumbent position
with the legs elevated, epinephrine will continue to be administered every 2 to 5
minutes, and fluids will be administered with vasopressors. Diphenhydramine is an
antihistamine used to treat allergy symptoms. Anticipating a tracheostomy may
occur with ongoing patient monitoring. Nitroprusside is a vasodilator and would
not be used now.
A colectomy is scheduled for a patient with ulcerative colitis. The nurse should
plan to include which prescribed measure in the preoperative preparation of this
patient?
Group of answer choices
Answers :Administration of a cleansing enema
What information would have the highest priority for the nurse to include in
preoperative teaching for a patient scheduled for a colectomy?
Answers :How to deep breathe and cough
Because anesthesia, an abdominal incision, and pain can impair the patient's
respiratory status in the postoperative period, it is of high priority to teach the
patient to cough and deep breathe.Otherwise, the patient could develop atelectasis
and pneumonia, which would delay early recovery from surgery and hospital
discharge.
, A colectomy is scheduled for a 38-year-old woman with ulcerative colitis. The
nurse should plan to include what prescribed measure in the preoperative
preparation of this patient?
Answers :Administration of a cleansing enema
RationalePreoperative preparation for bowel surgery typically includes bowel
cleansing with antibiotics, such as oral neomycin, and cleansing enemas, including
Fleet enemas. Instructions to irrigate the colostomy will be done postoperatively. A
clear liquid diet will be used the day before surgery with the bowel cleansing. Oral
antibiotics are given preoperatively and an IV antibiotic may be used in the
operating room.
A patient with severe anaphylactic reaction is experiencing hypovolemic shock.
What physiologic change will help the patient to compensate for the hemodynamic
imbalance?
Answers :
The nurse creates a plan of care for a patient who has had an allergic reaction to a
bee sting. What is the priority expected outcome for this patient?
Answers :This patient is at risk for development of an anaphylactic reaction.
Maintaining a clear and patent airway is a priority outcome with a patient who has
sustained a bee sting and has a known allergy to bees. Comfort and being free of
signs and symptoms of infection are important after ensuring airway patency and
breathing. Although the demonstration of self-administered epinephrine is likely
valuable for the allergic patient, immediately after the bee sting is not the best time
to engage in education because a delay in the administration of epinephrine could
result.Text Reference - p. 214
A patient is diagnosed with a latex allergy after having a reaction to interventions
provided in the acute care facility. Which preventive measures should the nurse
educate the patient about to avoid complications in the future?
