Chapter 20: Care of Patients with Hypersensitivity (Allergy) and Autoimmunity Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9edition

:MULTIPLE CHOICE 1. A nurse works in an allergy clinic. What task performed by the nurse takes priority? a. Checking emergency equipment each morning b. Ensuring informed consent is obtained as needed c. Providing educational materials in several languages d. Teaching clients how to manage their allergies ANS: A All actions are appropriate for this nurse; however, client safety is the priority. The nurse should ensure that emergency equipment is available and in good working order and that sufficient supplies of emergency medications are on hand as the priority responsibility. When it is appropriate for a client to give informed consent, the nurse ensures the signed forms are on the chart. Providing educational materials in several languages is consistent with holistic care. Teaching is always a major responsibility of all nurses. DIF: Applying/Application REF: 362 KEY: Immune disorders| inflammation| resuscitation| anaphylaxis| medical emergencies| patient safety MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 2. A client is in the preoperative holding area prior to surgery. The nurse notes that the client has allergies to avocados and strawberries. What action by the nurse is best? a. Assess that the client has been NPO as directed. b. Communicate this information with dietary staff. c. Document the information in the clients chart. d. Ensure the information is relayed to the surgical team. ANS: D A client with allergies to avocados, strawberries, bananas, or nuts has a higher risk of latex allergy. The nurse should ensure that the surgical staff is aware of this so they can provide a latex-free environment. Ensuring the clients NPO status is important for a client having surgery but is not directly related to the risk of latex allergy. Dietary allergies will be communicated when a diet order is placed. Documentation should be thorough but does not take priority. DIF: Applying/Application REF: 364 KEY: Allergic response| communication| patient safety| immune disorders MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction? a. Administering steroids for severe serum sickness b. Correctly identifying the client prior to a blood transfusion c. Keeping the client free of the offending agent d. Providing a latex-free environment for the client