Page 2197 - Saunders Comprehensive Review For NCLEX-RN

Oxygen is administered and an IV of normal saline is started and infused per PHCP
prescription. Documentation of the event, actions taken, and client outcomes needs
to be performed. The head of the bed should be elevated if the client’s blood
pressure is normal.
Test-Taking Strategy: Focus on the subject, interventions the nurse takes for an
anaphylactic reaction. Read each option carefully and remember that this is an
emergency. Think about the pathophysiology that occurs in this reaction to answer
correctly.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Planning
Content Area: Complex Care: Emergency Situations/Management
Health Problem: Adult Health: Immune: Hypersensitivity Reactions and Allergy
Priority Concepts: Clinical Judgment; Immunity
Reference: Ignatavicius, Workman, Rebar (2018), p. 365.

766. Answer: 3

Rationale: Pemphigus is an autoimmune disease that causes blistering in the
epidermis. The client has large flaccid blisters (bullae). Because the blisters are in the
epidermis, they have a thin covering of skin and break easily, leaving large denuded
areas of skin. On initial examination, clients may have crusting areas instead of intact
blisters. Option 1 describes eczema, option 2 describes herpes zoster, and option 4
describes psoriasis.
Test-Taking Strategy: Focus on the subject, the characteristics of pemphigus.
Think about the pathophysiology associated with this disorder and recall that
pemphigus vulgaris is an autoimmune disorder.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Evaluation
Content Area: Adult Health: Immune
Health Problem: Adult Health: Immune: Autoimmune Disease
Priority Concepts: Client Education; Immunity
Reference: Heuther & McCance (2017), p. 1065.

767. Answer: 1

Rationale: The client with immunodeficiency has inadequate or absence of
immune bodies and is at risk for infection. The priority nursing intervention would
be to protect the client from infection. Options 2, 3, and 4 may be components of care
but are not the priority.
Test-Taking Strategy: Note the strategic word, priority. Use Maslow’s Hierarchy
of Needs theory to answer the question. Remember that physiological needs are the
priority. This will direct you to the correct option.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Planning

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