An adolescent boy is admitted to the emergency department following a bee sting. He arrives with a body rash and 30 minutes later 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?

IgE-mediated response

Cell-mediated hypersensitivity

Autoimmune response

Type II hypersensitivity

Answer and Explanation

The Correct Answer is A

Choice A reason: An IgE-mediated (Type I) hypersensitivity reaction, like anaphylaxis, occurs post-bee sting, with rapid onset of rash, shortness of breath, hypotension, and tachycardia. IgE antibodies trigger mast cell degranulation, releasing histamine, causing vasodilation, bronchoconstriction, and systemic symptoms, matching the client’s acute presentation.

Choice B reason: Cell-mediated (Type IV) hypersensitivity involves T-cells, causing delayed reactions like contact dermatitis, not rapid systemic symptoms. Bee sting reactions are immediate, driven by IgE, not T-cells. Rash, hypotension, and respiratory distress indicate anaphylaxis, not a delayed cell-mediated response.

Choice C reason: Autoimmune responses involve self-directed antibodies, as in lupus, not triggered by external allergens like bee stings. The client’s acute rash, hypotension, and respiratory distress suggest an IgE-mediated anaphylactic reaction, not an autoimmune process, which is unrelated to acute allergen exposure.

Choice D reason: Type II hypersensitivity involves antibody-mediated cytotoxicity, as in transfusion reactions, not allergen-induced systemic symptoms. Bee sting reactions are IgE-driven, causing immediate anaphylaxis with rash and hypotension, not cytotoxic damage, making Type II inappropriate for the client’s acute presentation.

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Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: A foreign body in the eye may cause irritation or damage but is not a contraindication for ketorolac, a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation. The nurse would ensure removal of the foreign body first, but ketorolac can be used post-removal if indicated.

Choice B reason: Radiation exposure, such as from UV light, may cause photokeratitis but is not a specific contraindication for ophthalmic ketorolac. The medication reduces inflammation and pain, which may be beneficial in such cases. The nurse should assess for other ocular conditions, but radiation exposure alone does not preclude its use.

Choice C reason: Chemical burns require immediate irrigation and specific treatments based on the chemical involved. Ketorolac may reduce pain and inflammation post-irrigation, but it is not contraindicated. The nurse should prioritize burn management, but chemical burns do not inherently prohibit ketorolac use compared to corneal abrasions.

Choice D reason: Corneal abrasions are a contraindication for ophthalmic ketorolac, as NSAIDs can delay corneal healing and increase the risk of complications like corneal ulceration. The nurse must review the medical record to confirm the absence of abrasions, as ketorolac is typically used for postoperative pain, not traumatic corneal injuries.

A. Ascites B. Peripheral neuropathy C. Pulmonary edema D. Kidney stones

Correct Answer is A

Explanation

Choice A reason: Ascites, fluid accumulation in the peritoneal cavity, is a common complication of liver cirrhosis due to portal hypertension and hypoalbuminemia. It increases infection risk and discomfort, making it the priority to monitor, as early detection guides diuretic therapy and paracentesis.

Choice B reason: Peripheral neuropathy is not a primary cirrhosis complication, though it may occur in alcoholic liver disease. Ascites is more common, resulting from portal hypertension, making it the priority to monitor, as it directly reflects liver dysfunction and requires urgent management.

Choice C reason: Pulmonary edema is associated with heart failure, not cirrhosis. Ascites is a hallmark of cirrhosis, caused by portal hypertension and low albumin, making it the priority complication to monitor, as it indicates worsening liver function and requires immediate intervention.

Choice D reason: Kidney stones are unrelated to cirrhosis, which primarily causes ascites due to portal hypertension. Monitoring ascites is critical, as it reflects liver decompensation, increasing risks like spontaneous bacterial peritonitis, making it the priority over unrelated renal conditions.

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Naxlex Comprehensive Predictor Exams

A client receives a prescription for ophthalmic ketorolac. Prior to administering the medication, the nurse should review the electronic medical record for which condition?

Correct Answer is D

Explanation

The nurse is caring for a client with a history of liver cirrhosis. Which complication should the nurse monitor for?

Correct Answer is A

Explanation

Which intervention should the nurse implement to manage a client’s fluid and electrolyte balance?

The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

The nurse is caring for a client with a history of gout. Which dietary recommendation should the nurse emphasize?

The nurse is caring for a client with a history of chronic obstructive pulmonary disease who is receiving oxygen therapy. Which assessment should the nurse prioritize?

Which of the following best describes the primary source of energy for Earth's climate system?

The nurse is caring for a client with a history of depression who is prescribed a selective serotonin reuptake inhibitor (SSRI). Which side effect should the nurse monitor for?

The nurse is caring for a client with a new diagnosis of hyperthyroidism. Which intervention should the nurse prioritize?

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?