An adolescent boy is admitted to the emergency department (ED) following a bee sting. He arrives with a body rash and 30 minutes later he becomes short of breath. The nurse obtains vital signs with a blood pressure of 90/52 mm Hg, heart rate 130 beats/minute, and respiratory rate 40 breaths/minute. The client is exhibiting clinical manifestations of which type of immune reaction?

Cell-mediated tovity

Autoimmune response

IgE response hypersensitivity

Type II hypersensitivity

Answer and Explanation

The Correct Answer is C

Choice A reason: Cell-mediated hypersensitivity (Type IV) involves T-cells, causing delayed reactions like contact dermatitis, not acute symptoms like rash, hypotension, and dyspnea. Bee sting reactions are rapid, driven by IgE-mediated histamine release, making this immune mechanism incorrect for the client’s presentation.

Choice B reason: Autoimmune responses target self-antigens, as in lupus, not external allergens like bee venom. The client’s acute rash, hypotension, and respiratory distress indicate an allergic reaction, not autoimmunity, making this mechanism irrelevant to the anaphylactic response observed.

Choice C reason: IgE response hypersensitivity (Type I) causes anaphylaxis, as bee venom triggers IgE-mediated mast cell degranulation, releasing histamine. This leads to rash, hypotension, and bronchoconstriction, matching the client’s symptoms, making this the correct immune reaction for the acute, life-threatening presentation.

Choice D reason: Type II hypersensitivity involves antibody-mediated cytotoxicity, as in hemolytic anemia, not allergic reactions. Bee sting anaphylaxis results from IgE-driven histamine release, not cell destruction, making this mechanism incorrect for the client’s rapid-onset allergic symptoms.

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Correct Answer is A

Explanation

Choice A reason: Hemoglobin is critical to review, as diclofenac, an NSAID, can cause gastrointestinal bleeding, leading to anemia. Pale appearance and fatigue suggest blood loss, reducing oxygen-carrying capacity. Low hemoglobin confirms anemia, necessitating intervention to prevent further complications, making this the priority laboratory value.

Choice B reason: Serum creatinine monitors renal function, as diclofenac may cause nephrotoxicity, but pale appearance and fatigue point to anemia from bleeding, not renal issues. Renal effects are less immediate than blood loss, making hemoglobin more urgent to assess in this context.

Choice C reason: Blood glucose is irrelevant, as diclofenac does not significantly affect glucose metabolism. Pale appearance and fatigue are classic anemia symptoms, not hypoglycemia, making hemoglobin the priority over glucose, which does not explain the client’s presentation in rheumatoid arthritis.

Choice D reason: Liver enzymes monitor hepatotoxicity, a diclofenac side effect, but pale appearance and fatigue suggest anemia from gastrointestinal bleeding, not liver dysfunction. Hemoglobin directly addresses the likely cause, making it more critical than liver enzymes for immediate evaluation.

A. Test for Helicobacter pylori B. Give intravenous fluids C. Insert a rectal tube D. Monitor hemoglobin

Correct Answer is B

Explanation

Choice A reason: Testing for Helicobacter pylori is irrelevant, as vomiting and anorexia 8 days post-laparotomy suggest postoperative complications like ileus or obstruction, not peptic ulcer disease. H. pylori causes gastritis, not acute surgical issues, making this action inappropriate for the client’s current presentation.

Choice B reason: Giving intravenous fluids is critical, as vomiting and refusal to eat post-laparotomy risk dehydration and electrolyte imbalances. Fluids restore volume, stabilize hemodynamics, and support recovery from potential ileus or obstruction, addressing the client’s acute symptoms and preventing further deterioration.

Choice C reason: Inserting a rectal tube is inappropriate, as vomiting indicates upper gastrointestinal issues, not lower bowel obstruction. Post-laparotomy vomiting suggests ileus or adhesion, and rectal tubes do not address gastric or small bowel complications, making this action ineffective.

Choice D reason: Monitoring hemoglobin assesses blood loss, relevant post-laparotomy, but vomiting and anorexia prioritize fluid replacement to prevent dehydration. Hemoglobin checks are secondary, as fluid loss is the immediate threat, making IV fluids the more urgent intervention for stabilization.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is taking diclofenac for rheumatoid arthritis. During a clinic visit, the client appears pale and reports increasing fatigue. Which of the client’s serum laboratory values is most important for the nurse to review?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

A client with myasthenia gravis receives a new prescription for pyridostigmine. Which information should the nurse obtain prior to administering the medication?

A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?

A client with open-angle glaucoma asks the nurse how long the prescribed eye drops will need to be used. Which response made by the nurse is accurate?

To assess the quality of an adult client’s pain, which approach should the nurse use?

A client who is experiencing respiratory distress is admitted with respiratory acidosis. Which pathophysiological process supports the client’s respiratory acidosis?

A client with a history of chronic obstructive pulmonary disease (COPD) receives a new prescription for an ipratropium inhaler. Which action indicates to the nurse that additional teaching is needed?

A client with multiple sclerosis (MS) fell while walking to the bathroom. Upon transfer to the intensive care unit (ICU), the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?