Deck 19: Coordinating Care for Patients With Immune Disorders

Question 1

The nurse is providing care for a patient diagnosed with agammaglobulinemia and correlates management of this disorder includes which medication? Which is the anticipated treatment for this patient?
1)Oral diphenhydramine
2)Topical corticosteroids
3)Subcutaneous epinephrine
4)Intravenous immunoglobulin (IVIG)

Answer 1

4

Question 2

A nurse is caring for a patient with seasonal hypersensitivity reactions. What teaching does the nurse include in the patient's plan of care?
1)Keep doors and windows open to circulate air.
2)Maintain a clean, dust-free environment.
3)Avoid the use of diphenhydramine hydrochloride (Benadryl).
4)Stop taking oral corticosteroids once symptoms disappear.

Answer 2

2

Question 3

The nurse correlates systemic hypotension to which hypersensitivity mediator?
1)Kinins
2)Leukotrienes
3)Platelet-activating factor
4)Prostaglandin

Answer 3

3

Question 4

The nurse monitors for which clinical manifestations in the patient diagnosed with X-linked agammaglobulinemia (XLA)?
1)Wheezes
2)Stridor
3)Tachypnea
4)Hyper-resonant breath sounds

Question 5

The nursing diagnosis Potential for Ineffective Airway Clearance is most relevant to a patient with which immune disorder?
1)B-cell deficiency
2)T-cell deficiency
3)Type I hypersensitivity reaction
4)X-linked agammaglobulinemia

Question 6

Which immune disorder does the nurse include in the plan of care for a patient who is receiving chemotherapeutic agents for the treatment of cancer?
1)B-cell deficiency
2)T-cell deficiency
3)Excessive immune response
4)Secondary immune deficiency

Question 7

The nurse recognizes which immunoglobulin (Ig) as the mediator for a type I hypersensitivity reaction?
1)IgA
2)IgE
3)IgG
4)IgM

Question 8

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)Notify the healthcare provider.
2)Administer prescribed diphenhydramine (Benadryl) by mouth every 4 hours.
3)Administer prescribed epinephrine 1:1,000 by subcutaneous injection per the healthcare provider's orders.
4)Obtain a complete set of vital signs.

Question 9

The nurse is providing care to a patient diagnosed with X-linked agammaglobulinemia (XLA). Which information does the nurse include in the patient's plan of care?
1)Immunization with inactivated polio vaccine (IPV)
2)Administration of intravenous immunoglobulin every 6 months
3)Education regarding the use of high-dose prophylactic antibiotics
4)Periodic magnetic resonance imagery (MRI) to monitor for respiratory complications

Question 10

The nurse is caring for a patient who is experiencing anaphylactic shock after 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's position

Question 11

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

Question 12

The nurse correlates which laboratory value as a complication in the patient diagnosed with DiGeorge's syndrome?
1)Sodium 150 mEq/L
2)Calcium 6.5 mg/dL
3)Potassium 3.0 mEq/L
4)Magnesium 2.5 mg/dL

Question 13

A nurse has been providing a 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 has not expired."
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."

Question 14

Which is the priority nursing action to decrease the risk for infection for a patient diagnosed with DiGeorge's syndrome?
1)Hand hygiene
2)Reverse isolation
3)Prokinetic agents
4)Droplet precautions

Question 15

The nurse provides education to the parents of a pediatric patient who is diagnosed with X-linked agammaglobulinemia (XLA). Which statement indicates a need for additional teaching?
1)"I will take my child to the pediatrician if he begins to pull at his ear."
2)"My other children can receive the live attenuated oral polio vaccine."
3)"I will clean all vegetables and fruits before giving them to my child."
4)"My child will likely require intravenous antibiotics for respiratory infections."

Question 16

The nurse provides care to several patients with a history of hypersensitivity reactions. Which patient requires education regarding a type I reaction?
1)The patient with allergic rhinitis
2)The patient with myasthenia gravis
3)The patient with rheumatoid arthritis
4)The patient with a suspected latex allergy

Question 17

What is the priority nursing diagnosis for a patient diagnosed with X-linked agammaglobulinemia (XLA)?
1)Risk for Infection
2)Decreased Cardiac Output
3)Body Image Disturbance
4)Fatigue

Question 18

A nurse is caring for a 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

Question 19

The nurse monitors for which clinical manifestation in the patient diagnosed with DiGeorge's syndrome?
1)Muscle stiffness
2)Weight gain
3)Shortness of breath
4)Aphasia

Question 20

The nurse educates a patient who is diagnosed with therapy-induced immune dysfunction. Which patient statement indicates the need for additional teaching?
1)"My husband cleans the cat's litter box."
2)"We are planning to get our son an iguana for his birthday."
3)"I ensure that my steak is well done when I eat out at a restaurant."
4)"When I need to go shopping, I will go early in the morning to avoid crowds."

Question 21

The nurse is preparing to assess a patient when one of the patient's family members begins showing symptoms of a mild latex sensitivity. Which action by the nurse is best?
1)Asking the family member to leave the unit
2)Transferring the patient to a department that does not use latex products
3)Reporting the problem to the supervisor of the unit
4)Obtaining latex-free products for the patient's room

Question 22

The nurse recognizes that the local reaction typical of a positive tuberculosis test, including a wheal and flare reaction, is observed in which type of hypersensitivity reaction?
1)Type I
2)Type II
3)Type III
4)Type IV

Question 23

The nurse correlates which type of hypersensitivity reaction to a patient with myasthenia gravis?
1)Type I
2)Type II
3)Type III
4)Type IV

Question 24

In preparing a patient for a blood transfusion, the nurse recognizes that a patient with blood type B can receive which blood types? Select all that apply.
1)Type A
2)Type B
3)Type AB
4)Type O
5)Only autologous blood

Question 25

The nurse monitors for which clinical manifestations in the patient experiencing a histamine-mediated hypersensitivity reaction? Select all that apply.
1)A report of itching
2)Elevated blood pressure
3)The presence of hives
4)The presence of vomiting
5)Wheezing on auscultation

Question 26

The nurse working on the maternal-child unit understands that erythroblastosis fetalis, which is due to Rh sensitization, is an example of which type of hypersensitivity reaction?
1)Type I hypersensitivity reaction
2)Type II hypersensitivity reaction
3)Type III hypersensitivity reaction
4)Type IV hypersensitivity reaction

Question 27

The nurse correlates which disorders to type III systemic hypersensitivity reactions? Select all that apply.
1)Anaphylactic shock
2)Myasthenia gravis
3)Rheumatoid arthritis
4)Serum sickness
5)Systemic lupus erythematous (SLE)

Question 28

What is the priority nursing action to decrease the risk of a blood transfusion reaction from a patient receiving incompatible blood?
1)Assessing the patient's vital signs before starting the transfusion
2)Documenting the procedure in the health record
3)Verifying the patient's identity using two identifiers
4)Checking the bag to ensure it is the correct blood type

Question 29

A nurse is working in a summer camp. One of the campers comes to the clinic with several bee stings. Which clinical manifestations would require administration of epinephrine (EpiPen)? Select all that apply.
1)Skin that is cold and clammy to the touch
2)Skin that is warm and dry to the touch
3)Hyperactive and hyperverbal behavior
4)Wheezing
5)Restlessness and confusion

Question 30

The nurse is providing care to a patient who is being evaluated for an immune deficiency. Which information in the patient's health history supports this diagnosis? Select all that apply.
1)Persistent oral thrush
2)Rare need for antibiotics in the past
3)One occurrence of pneumonia last year
4)Eight new infections in a 1-year period
5)Two serious sinus infections in a 1-year period