Chapter 20: Coordinating Care for Patients With Immune Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. 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?
1. Erythema
2. Fever
3. Joint pain
4. Hypotension
____ 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?
1. 26 years of age
2. Caucasian race
3. Previous antibiotic therapy
4. Concurrent chronic illness
____ 3. 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 meningocele
repair. Based on this data, which product should be avoided when providing care to
this patient?
1. Synthetic rubber gloves
2. Polyethylene gloves
3. Nonpowdered nitrile gloves
4. Latex gloves
____ 4. 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?
1. A history of an anaphylactic reaction to shellfish.
2. A drug reaction to penicillin causing a rash.
3. A history of glomerulonephritis.
4. A history of dermatitis resulting from a response to changing laundry detergent.
, ____ 5. 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?
1. Ask the family member to leave the unit
2. Transfer the patient to a department that does not use latex products
3. Wait until Monday to report the problem to the supervisor of the unit
4. Obtain latex-free products for the patient’s room
____ 6. 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?
1. Trendelenburg position
2. Flat, with legs slightly elevated
3. Supine position
4. High Fowler position
____ 7. 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?
1. Teach the patient regarding using a kit that contains treatment for allergic reactions.
2. Administer diphenhydramine (Benadryl) by mouth every four hours per the health-
care provider's orders.
3. Administer epinephrine 1:1,000 by subcutaneous injection per the health-care
provider's orders.
4. Collect a detailed history from the patient regarding the history of latex allergies.
____ 8. 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?
1. “I make sure the EpiPen is always available.”
2. “It's fine to leave the EpiPen out in the sun.”
3. “No one else in my family knows how to use the EpiPen.”
4. “I don't need a medical alert tag.”
____ 9. 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?
, 1. “This medication does not come prefilled and must be measured.”
2. “Keep the medication in the car at all times.”
3. “Frequently check the expiration date of the medication.”
4. “Keep the medication in one location that is easy to remember.”
____ 10. A nurse is caring for a patient with seasonal hypersensitivity reactions. What
teaching would the nurse provide to improve this patient’s comfort?
1. Keep doors and windows open on high-allergen days to circulate air.
2. Maintain a clean, dust-free environment.
3. Take antihistamine and leukotriene medication as ordered.
4. Stop taking oral corticosteroids immediately once symptoms disappear.
____ 11. The nurse suspects that the patient is experiencing a reaction to a specific
antigen. Which laboratory result supports the conclusion made by the nurse?
1. Indirect Coombs’ showing no agglutination.
2. Patch test with a 1-inch area of erythema.
3. 2% eosinophils in the WBC count.
4. Rh antigen with negative results.
____ 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?
1. Epinephrine
2. Azathioprine
3. Cyclosporine
4. Mycophenolate mofetil
____ 13. 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?
1. Epinephrine
2. Azathioprine
3. Cyclosporine
4. Mycophenolate mofetil
____ 14. 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?
1. Epinephrine
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. 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?
1. Erythema
2. Fever
3. Joint pain
4. Hypotension
____ 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?
1. 26 years of age
2. Caucasian race
3. Previous antibiotic therapy
4. Concurrent chronic illness
____ 3. 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 meningocele
repair. Based on this data, which product should be avoided when providing care to
this patient?
1. Synthetic rubber gloves
2. Polyethylene gloves
3. Nonpowdered nitrile gloves
4. Latex gloves
____ 4. 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?
1. A history of an anaphylactic reaction to shellfish.
2. A drug reaction to penicillin causing a rash.
3. A history of glomerulonephritis.
4. A history of dermatitis resulting from a response to changing laundry detergent.
, ____ 5. 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?
1. Ask the family member to leave the unit
2. Transfer the patient to a department that does not use latex products
3. Wait until Monday to report the problem to the supervisor of the unit
4. Obtain latex-free products for the patient’s room
____ 6. 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?
1. Trendelenburg position
2. Flat, with legs slightly elevated
3. Supine position
4. High Fowler position
____ 7. 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?
1. Teach the patient regarding using a kit that contains treatment for allergic reactions.
2. Administer diphenhydramine (Benadryl) by mouth every four hours per the health-
care provider's orders.
3. Administer epinephrine 1:1,000 by subcutaneous injection per the health-care
provider's orders.
4. Collect a detailed history from the patient regarding the history of latex allergies.
____ 8. 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?
1. “I make sure the EpiPen is always available.”
2. “It's fine to leave the EpiPen out in the sun.”
3. “No one else in my family knows how to use the EpiPen.”
4. “I don't need a medical alert tag.”
____ 9. 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?
, 1. “This medication does not come prefilled and must be measured.”
2. “Keep the medication in the car at all times.”
3. “Frequently check the expiration date of the medication.”
4. “Keep the medication in one location that is easy to remember.”
____ 10. A nurse is caring for a patient with seasonal hypersensitivity reactions. What
teaching would the nurse provide to improve this patient’s comfort?
1. Keep doors and windows open on high-allergen days to circulate air.
2. Maintain a clean, dust-free environment.
3. Take antihistamine and leukotriene medication as ordered.
4. Stop taking oral corticosteroids immediately once symptoms disappear.
____ 11. The nurse suspects that the patient is experiencing a reaction to a specific
antigen. Which laboratory result supports the conclusion made by the nurse?
1. Indirect Coombs’ showing no agglutination.
2. Patch test with a 1-inch area of erythema.
3. 2% eosinophils in the WBC count.
4. Rh antigen with negative results.
____ 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?
1. Epinephrine
2. Azathioprine
3. Cyclosporine
4. Mycophenolate mofetil
____ 13. 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?
1. Epinephrine
2. Azathioprine
3. Cyclosporine
4. Mycophenolate mofetil
____ 14. 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?
1. Epinephrine
