Chapter 53 Medical Surgical Nursing Preparation For Practice 2nd Edition By Osborn

Chapter 53 Medical Surgical Nursing Preparation For Practice 2nd Edition By Osborn

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

Question 1

Type: MCSA

A patient with a history of latex allergy has developed itching and hives after being admitted for a fractured left femur. What initial nursing action is indicated?

1. Survey the patient’s room for possible latex-containing items.
2. Ask if the patient is experiencing any difficulty breathing.
3. Alert the patient’s health care provider concerning the symptoms.
4. Collect a detailed history from the patient regarding the allergy.

Correct Answer: 2

Rationale 1: Attempting to locate latex-containing items is not the nurse’s priority.

Rationale 2: A history of latex allergy in combination with the patient’s symptoms would alert the nurse to the possibility of an allergic reaction. Such reactions can result in respiratory distress, so assessment of the airway is the nursing priority.

Rationale 3: The health care provider should be alerted, but this is not the nurse’s immediate priority.

Rationale 4: Conducting a nursing history is not the immediate priority.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 53-1

Question 2

Type: MCSA

A patient is suspected of having an allergic reaction to certain laundry detergents. The nurse recognizes that which diagnostic test result would best confirm a hypersensitivity reaction?

1. Rh antigen with negative results
2. Eosinophils of 2% of the total WBC
3. Prick test with 3 mm erythema
4. Indirect Coombs’ showing no agglutination

Correct Answer: 3

Rationale 1: Rh antigen results that are negative reflect the absence of the Rh factor in the blood. This result is not associated with hypersensitivity reaction.

Rationale 2: Eosinophils do increase with hypersensitivity reaction, but this result is within normal limits.

Rationale 3: Positive results from a prick test include wheal and flare of at least 3 mm.

Rationale 4: The indirect Coombs’ test detects the presence of circulating antibodies against RBCs. This result is not associated with hypersensitivity reaction.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 53-1

Question 3

Type: MCSA

A patient who believes he has a peanut allergy presents at the emergency department concerned because he has ingested a small amount of commercially prepared food that may have contained peanut oil. Which nursing question best addresses the patient’s risk for injury?

1. “Did you self-administer epinephrine?”
2. “What makes you think you are allergic to peanuts?”
3. “Have you every undergone testing for a peanut allergy?”
4. “Have you ever experienced an allergic reaction to peanuts before?”

Correct Answer: 4

Rationale 1: Self-administration of epinephrine is directed more toward management of a reaction than confirming the possibility of a reaction.

Rationale 2: This question will elicit important information, but it is not the first question the nurse should ask.

Rationale 3: The nurse should ask about testing, but this is not the priority question.

Rationale 4: The priority is to determine whether the patient is allergic to peanuts and at risk for injury in the form of an allergic reaction. Confirming a past reaction to the ingestion of peanuts is the best way to determine that possibility at this time.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 53-1

Question 4

Type: MCMA

The nurse is providing discharge education for a patient who experienced an anaphylactic reaction to a bee sting. To ensure that the patient receives prompt, appropriate medical care in the event of another bee sting, the nurse encourages which actions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Carry oral antihistamines at all times.
2. Be aware of how quickly the symptoms occur and exacerbate.
3. Always have quick access to an epinephrine pen.
4. Wear a medical alert bracelet that identifies allergy to bee venom.
5. Be able to identify early symptoms of allergic reaction.

Correct Answer: 2,3,4,5

Rationale 1: Oral medications would not work rapidly enough in case of another episode of anaphylaxis.

Rationale 2: Being aware of symptoms and the speed with which anaphylactic shock can develop will be vital to the patient’s receiving prompt, appropriate medical care.

Rationale 3: Carrying a self-administered epinephrine kit to use in the event of an anaphylactic reaction is essential.

Rationale 4: The nurse can promote patient health and safety by encouraging patients with a history of anaphylactic reactions to wear a medical alert bracelet or other form of medical identification tag that identifies allergies.

Rationale 5: The patient who can self-assess for symptoms of allergic reaction will be able to initiate treatment earlier.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 53-1