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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Correct Answer is A

Explanation

Choice A reason: Limiting potassium-rich foods is critical in chronic kidney disease, as impaired renal excretion causes hyperkalemia, risking cardiac arrhythmias. Foods like bananas and oranges are restricted to maintain safe potassium levels, making this the priority dietary teaching to prevent life-threatening complications.

Choice B reason: Increasing protein intake is inappropriate, as chronic kidney disease requires protein restriction to reduce uremic toxins and kidney workload. Potassium restriction is prioritized, as hyperkalemia poses an immediate cardiac risk, making it the essential dietary focus over protein adjustments.

Choice C reason: Restricting carbohydrates is not standard in chronic kidney disease unless diabetes is present. Potassium restriction is critical, as elevated potassium levels from impaired renal clearance cause arrhythmias, making it the priority dietary intervention to ensure cardiac safety.

Choice D reason: Encouraging high-sodium foods is incorrect, as sodium restriction prevents fluid retention and hypertension in chronic kidney disease. Potassium restriction is the priority, as hyperkalemia directly threatens cardiac function, making it the essential dietary focus over sodium concerns.

A. Monitor for respiratory depression B. Assess for constipation C. Check for skin rash D. Evaluate for nausea

Correct Answer is A

Explanation

Choice A reason: Hydromorphone, an opioid, poses a significant risk of respiratory depression by suppressing the brainstem’s respiratory centers. After four days, cumulative effects increase this risk, especially in opioid-naïve patients. Monitoring respiratory rate and depth is critical to prevent life-threatening hypoxia, making it the priority assessment.

Choice B reason: Constipation is a common hydromorphone side effect due to opioid-induced reduced gastrointestinal motility. While important, it is not life-threatening like respiratory depression. Monitoring bowel function is secondary, as respiratory compromise poses an immediate risk requiring urgent intervention in opioid therapy.

Choice C reason: Skin rash is a rare allergic reaction to hydromorphone, not a primary concern after four days of use. Respiratory depression is far more critical, as opioids directly depress respiratory drive, risking hypoxia, making rash assessment secondary to monitoring respiratory function.

Choice D reason: Nausea is a frequent hydromorphone side effect, often diminishing with continued use. While bothersome, it is not life-threatening compared to respiratory depression, which can cause rapid hypoxia. Monitoring respiratory status is the priority to ensure patient safety during opioid administration.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a history of chronic kidney disease. Which dietary restriction should the nurse emphasize?

Correct Answer is A

Explanation

The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

Correct Answer is A

Explanation

The nurse is caring for a client with a history of deep vein thrombosis. Which intervention should the nurse include in the care plan?

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

The nurse is caring for a client with a new diagnosis of epilepsy who is prescribed phenytoin. Which teaching point should the nurse emphasize?

Which technique should the nurse use when assessing for early signs of rheumatoid arthritis?

A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell. The nurse obtains a nasal swab for COVID-19 testing. Which action is most important for the nurse to take?

A client is admitted to the emergency department with a suspected myocardial infarction. Which laboratory test should the nurse prioritize to confirm the diagnosis?

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 teaching a client with gastroesophageal reflux disease about dietary modifications. Which instruction should the nurse include?