Hypersensitivity reactions
Allergic reaction
What is hypersensitivity type 1
Explain what TID means
Three times a day
Which statement best describes how HIV causes immunosuppression?
A. HIV destroys B lymphocytes
B. HIV inhibits antibody production
C. HIV targets CD4 T-helper cells
D. HIV suppresses bone marrow
What is HIV binds to CD4 receptors, leading to progressive loss of T-helper cells and immune dysfunction.
Lab finding altered during infection and give a value
What is A normal White Blood Cell (WBC) count for adults is typically between 4,500 to 11,000 cells per microliter (mcL), so what is > 11,000
A client develops wheezing, hypotension, and urticaria within minutes of receiving IV penicillin. Which hypersensitivity reaction is occurring?
What is type 1 reaction
Hemolytic Disease of the Newborn
What is type II hypersensitivity reaction
A nurse is preparing to administer medications through a PEG tube for a client receiving continuous enteral feeding. Which medication order requires the nurse to question the prescription?
A. Acetaminophen liquid
B. Metoprolol extended-release tablet
C. Potassium chloride liquid
D. Famotidine oral suspension
Explain why
What is Extended-release (ER) medications must not be crushed because doing so destroys the controlled-release mechanism, potentially causing dose dumping and toxicity. ER formulations are contraindicated for PEG/NG administration unless a liquid or immediate-release alternative is prescribed.
A client has oral candidiasis and a CD4 count of 150 cells/mm³. How should this be interpreted?
What is the patient has AIDS
Please state three signs of inflammation
What are redness, heat, swelling, and pain, often accompanied by a loss of function in the affected area, like stiffness or reduced movement; these occur as the body increases blood flow to fight infection or injury. Systemic signs can include fever, fatigue, and weight loss,
Which medication should the nurse administer FIRST for a client experiencing anaphylaxis?
What is epinephrine
Type II hypersensitivity reaction definition
What is ANTIBODIES ATTACK CELLS
Before administering medications through an NG tube, which action is most appropriate to verify tube placement?
What is Checking gastric pH (≤5.5) is a more reliable method than auscultation, which is no longer considered best practice. Proper placement verification reduces the risk of aspiration and medication misadministration.
A client with HIV presents with dyspnea, nonproductive cough, and hypoxia. Chest X-ray shows diffuse bilateral infiltrates. Which infection is most likely?
What is Pneumocystis jirovecii pneumonia (PJP)
A nurse is caring for a client with confirmed Clostridioides difficile infection. The nurse removes gloves after providing perineal care, performs hand hygiene with alcohol-based sanitizer, and then exits the room. Later, another client on the unit develops C. difficile infection. Which link in the chain of infection was most likely not properly interrupted?
What is C. difficile spores are not effectively eliminated by alcohol-based hand sanitizer. The nurse should have performed handwashing with soap and water. Failure to interrupt the mode of transmission allowed spores to spread to another client. While the portal of exit existed, the primary failure was inadequate interruption of transmission.
Type II hypersensitivity reactions cause tissue injury primarily through:
What is . Antibody-mediated cell destruction
Immune complexes = garbage floating in blood that gets stuck in filters
What is type III reaction
A client receiving nutrition through an NG tube is prescribed digoxin tablets. What is the nurse’s best action?
What is check to see if it can be crushed (it cannot) so call physician for liquid order
Which statement by a client with an undetectable viral load indicates correct understanding?
A. “I cannot transmit HIV to anyone.”
B. “I still need to use barrier protection.”
C. “My immune system is fully normal now.”
D. “I no longer need routine lab monitoring.”
What is continued barrier protection teaching, especially for STI prevention and real-world adherence concerns.
A hospitalized client with an indwelling urinary catheter develops a urinary tract infection. The nurse notes that catheter care was performed daily, but the drainage bag was routinely placed on the floor during ambulation. Which link in the chain of infection was most directly compromised?
What is Placing the drainage bag on the floor allows it to become a reservoir for microorganisms. These organisms can then ascend the catheter and enter the urinary tract. While the catheter provides a portal of entry, the root failure was allowing a contaminated reservoir to develop.
Which condition is caused by antibodies blocking acetylcholine receptors at the neuromuscular junction?
What is myasthenia gravis
A patient eats peanuts and within minutes develops wheezing, hives, and hypotension.
A nurse is caring for a client with a PEG tube who is receiving continuous enteral feedings. The provider orders metoprolol 25 mg PO daily. The nurse crushes the tablet, mixes it with water, and administers it through the PEG tube. Later that shift, the nurse reviews the medication administration record and notices that the medication was documented as “given PO”. The client’s heart rate later drops to 48 bpm, and the provider questions whether the medication was administered correctly. Which right of medication administration was compromised in this scenario?
What is The medication was ordered as PO (by mouth) but was administered through a PEG tube, which is a different route and must be documented correctly. Administering a medication via a route other than what is ordered violates the Right Route
Which isolation precaution is required for a hospitalized client with HIV?
What is standard precautions
A nurse is preparing to care for a client diagnosed with Clostridioides difficile infection who has frequent diarrhea. Which PPE should the nurse don before entering the room?
What is C. difficile requires contact precautions. Gloves and gown are required due to the high risk of environmental contamination and spore transmission. A mask or respirator is not required unless there is a risk of splashing. Hand hygiene must be performed with soap and water, but that is not PPE.
A client with systemic lupus erythematosus presents with joint pain, rash, and decreased complement levels. Which hypersensitivity reaction is responsible?
Delayed rash after exposure
What is Type IV hypersensitivity reaction
A nurse administers hydromorphone 0.5 mg IV to a postoperative client for pain. Thirty minutes later, the nurse realizes the medication vial was labeled hydromorphone 1 mg/mL, and the entire 1 mL was administered. Which right of medication administration was most directly violated?
What is right dose
What finding indicates effective antiretroviral therapy?
What is an undetectable viral load
A client is admitted with suspected bacterial meningitis. Which PPE is required for the nurse when providing routine care?
What is Bacterial meningitis requires droplet precautions. A surgical mask is required when within close proximity (usually within 3–6 feet).
A client receiving long-term corticosteroid therapy is at increased risk for infection primarily because these medications:
What is Suppress inflammatory and immune responses
T cells (NO antibodies)
What is type IV reaction
A nurse administers morphine to a client for pain. Which action best demonstrates adherence to the right evaluation?
Reassessing pain and respiratory status 30 min after administration
Which nursing intervention is the highest priority for a client with advanced AIDS and multiple opportunistic infections?
A. Aggressive curative treatment
B. Strict isolation
C. Symptom management and comfort
D. High-calorie diet only
What is In advanced AIDS, care often shifts toward palliative goals, emphasizing comfort, symptom control, and quality of life.
A nurse is caring for four clients. Which client requires immediate assessment?
A. Client with a temperature of 38.1°C (100.6°F) receiving oral antibiotics
B. Client with a surgical wound draining serous fluid
C. Client with chills, hypotension, and tachycardia
D. Client with a WBC count of 12,000/mm³
What is Chills, hypotension, and tachycardia are early signs of sepsis, a life-threatening complication of infection requiring immediate intervention.
Failure of the immune system to distinguish self from non-self most directly results in:
What is autoimmune disease
Post-strep glomerulonephritis
What is type III hypersensitivity reaction
A nurse prepares to administer potassium chloride, a high alert medication, to a client with hypokalemia. Which action is most critical to ensure medication safety?
What is Potassium is a high-alert medication. Independent double-checks are required to prevent fatal dosing errors.
A client with HIV presents with blurred vision and floaters. CD4 count is 45 cells/mm³. Which opportunistic infection does the nurse suspect?
What is CMV retinitis is associated with CD4 <50 and causes visual changes, including floaters and blurred vision, which can progress to blindness.
A nurse receives an order to administer IV antibiotics to a client with suspected sepsis. Blood cultures are ordered but not yet drawn. What is the nurse’s best action?
What is Blood cultures should be obtained before antibiotics to identify the pathogen, but antibiotics must not be significantly delay
A client develops erythema and induration at a tuberculin skin test site 72 hours after administration. Which immune mechanism is responsible?
What is T-cell–mediated delayed inflammation
A client receives an antivenom injection and develops fever, joint pain, and a generalized rash 8 days later. Which hypersensitivity reaction is most likely responsible?
What is Delayed onset (days after exposure) with fever, arthralgia, and rash is classic for serum sickness, a Type III immune complex–mediated reaction.
A nurse scans a client’s wristband before administering medication, but the scanner fails. Which action best ensures the right patient?
What is The right patient requires two approved identifiers (e.g., name and date of birth). Room number and staff confirmation are not reliable identifiers.
A client presents with fever, sore throat, lymphadenopathy, and a maculopapular rash 3 weeks after a high-risk exposure. Which interpretation is most accurate?
What is These symptoms are characteristic of acute retroviral syndrome, which occurs 2–4 weeks after infection, before antibodies are detectable.
Which finding best indicates that antibiotic therapy for infection is effective?
A. White blood cell count returns to normal
B. Temperature decreases within 1 hour
C. Pain level decreases
D. Appetite improves
What is A normalizing WBC count is the most objective indicator of infection resolution. Temperature and symptoms may fluctuate and are less reliable alone.
A nurse administers IV penicillin to a client who develops hypotension, wheezing, and urticaria within minutes. The nurse immediately administers epinephrine. Which immunologic event occurred FIRST in this reaction?
A. Complement activation
B. IgE cross-linking on mast cells
C. Cytokine release from T cells
D. Immune complex deposition
What is In Type I hypersensitivity, the initial triggering event is IgE cross-linking on mast cells, leading to rapid degranulation and mediator release.