Page 2198 - Saunders Comprehensive Review For NCLEX-RN

Content Area: Adult Health: Immune
Health Problem: Adult Health: Immune: Immunodeficiency syndrome
Priority Concepts: Immunity; Safety
Reference: Lewis et al. (2017), pp. 205-206.

768. Answer: 2

Rationale: In some types of allergies, a reaction occurs only on second and
subsequent contacts with the allergen. The appropriate action, therefore, would be to
ask the client if he ever experienced a bee sting in the past. Option 1 is not
appropriate advice. Option 3 is unnecessary. The client should not be told “not to
worry.”
Test-Taking Strategy: Use the steps of the nursing process to answer the
question. The correct option is the only one that addresses assessment.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Adult Health: Immune
Health Problem: Adult Health: Immune: Hypersensitivity Reactions and Allergy
Priority Concepts: Clinical Judgment; Immunity
Reference: Ignatavicius, Workman, Rebar (2018), p. 140.

769. Answer: 1

Rationale: Individuals most at risk for developing a latex allergy include health
care workers; individuals who work in the rubber industry; or those who have had
multiple surgeries, have spina bifida, wear gloves frequently (such as food handlers,
hairdressers, and auto mechanics), or are allergic to kiwis, bananas, pineapples,
tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts.
Test-Taking Strategy: Focus on the subject, a latex allergy, and note the strategic
word, most. Recalling the sources of latex and of the allergic reaction will direct you
easily to the correct option.
Level of Cognitive Ability: Analyzing
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Immune
Health Problem: Adult Health: Immune: Hypersensitivity Reactions and Allergy
Priority Concepts: Health Promotion; Immunity
Reference: Ignatavicius, Workman, Rebar (2018), pp. 234-235, 419.

770. Answer: 1, 2, 4, 5

Rationale: If a client is allergic to latex and is at high risk for an allergic response,
the nurse would use nonlatex gloves and latex-safe supplies, and would keep a
latex-safe supply cart available in the client’s area. Any supplies or materials that
contain latex would be avoided. These include blood pressure cuffs and medication
vials with rubber stoppers that require puncture with a needle. It is not necessary to

2198