ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 34 : Caring for Clients With Immune-Mediated Disorders Questions
Question 1 of 5
The nurse is talking with a client who was stung by a bee and began having difficulty breathing. What serious complication from injected venom should the nurse discuss with the client?
Correct Answer: C
Rationale: Injectants, such as bee venom, and some other allergens can produce systemic and potentially fatal effects, including shock and airway obstruction caused by laryngeal swelling. Although all other answers can occur with an allergen, they are not the most serious complication.
Question 2 of 5
A client is scheduled to have a prick test to determine what specific allergens are creating problems for the client. What should the nurse inform the client is involved with the testing?
Correct Answer: C
Rationale: The scratch or prick test involves scratching the skin and applying a small amount of the liquid test antigen to the scratch. The tester applies one allergen per scratch over the client's forearm, upper arm, or back. The back is more sensitive than the arm. Results of the test are identifiable in as little as 20 minutes. If a raised wheal with localized erythema appears, the tester measures its length and width in millimeters. The client does not taste in any of the skin tests.
Question 3 of 5
A client informs the nurse of being very allergic to poison ivy but expresses enjoying and having several camping trips planned for the summer months. What suggestions can the nurse make to protect the client against poison ivy?
Correct Answer: B
Rationale:
To protect against poison ivy, clients can apply bentoquatam 5% to the skin 15 minutes prior to exposure and at least every 4 hours as long as risk of exposure continues. The cream forms a protective layer on top of the skin. Calamine lotion can be used for the itching related to poison ivy exposure. Vinegar and water is not an effective way to manage the prevention of poison ivy. Benadryl will not protect against poison ivy.
Question 4 of 5
The nurse is interviewing a client being admitted to the hospital and inquires about any allergies the client has. The client reports being allergic to aspirin and penicillin. What intervention should the nurse provide immediately to prevent complications related to allergies?
Correct Answer: A
Rationale: The nurse asks each client about the existence of any allergies. If any are reported, the nurse flags the medical record and applies a wristband with the appropriate information. Throughout the client's care, the nurse observes for signs of an allergic reaction, especially when administering medication, applying substances such as tape or adhesive patches to the skin. Medication should never be left in the client's room. The responsibility for medications with the identified allergens lies with the healthcare personnel in the acute care facility. The physician does not need to be called if the chart is flagged.
Question 5 of 5
A client has an allergic reaction to seafood with generalized edema and reports being unable to get a wedding ring off as it is too tight. The client was unable to remove it with soap and water. What action by the nurse can facilitate removal of the ring without damaging it?
Correct Answer: C
Rationale: If applying soap or oil to the finger proves unsuccessful, the nurse may wrap the finger with twine. Once the tissue is compressed, the ring can be removed by pulling on the free end of the twine. This technique is preferable to damaging the ring with a metal cutter. If nothing else facilitates ring removal, however, cutting the ring is a better option than allowing damage from ischemia to develop. The nurse cannot administer a diuretic without a physician's prescription, and allowing the swelling to go down may cause tissue ischemia from the constricted ring. There are options other than cutting the ring, but if they fail, there is no other choice. A tongue blade will not remove a ring that is too tight.