What is the priority action for the nurse to take for a client who develops an anaphylactic reaction?

Anaphylactic shock NCLEX questions for nursing students!

This quiz will test your knowledge on anaphylactic shock. Anaphylactic shock occurs when a foreign substance enters the body and causes the mast cells and basophils to release histamine and other inflammatory mediators system-wide. This causes major vasodilation, bronchoconstriction, and increase capillary permeability, which will alter cardiac output and decrease tissue perfusion. This leads to cell hypoxia and eventually multiple organ dysfunction syndrome (MODS) and death.

Don’t forget to watch the lecture on anaphylactic shock before taking the quiz.

There are various types of shock: cardiogenic, hypovolemic, anaphylactic, septic, and neurogenic.

(NOTE: When you hit submit, it will refresh this same page. Scroll down to see your results.)

1. Your patient is having a sudden and severe anaphylactic reaction to a medication. You immediately stop the medication and call a rapid response. The patient’s blood pressure is 80/52, heart rate 120, and oxygen saturation 87%. Audible wheezing is noted along with facial redness and swelling.  As the nurse you know that the first initial treatment for this patient’s condition is?

A. IV Diphenhydramine

B. IV Normal Saline Bolus

C. IM Epinephrine

D. Nebulized Albuterol

The answer is C. IM or subq Epinephrine is the first-line treatment for anaphylaxis. Epinephrine will cause vasoconstriction (this will increase the blood pressure and decrease swelling) and bronchodilation (this will dilate the airways). This patient’s cardiovascular and respiratory system is compromised. Therefore, epinephrine will provide fast relief with anaphylaxis.

2. A 25-year-old female is admitted to the ER in anaphylactic shock due to a bee sting. According to the patient’s mother, the patient is severely allergic to bees and was recently stung by one. This type of anaphylactic reaction is known as a?

A. Type I Hypersensivity Reaction

B. Type II Hypersensivity Reaction

C. Type III Hypersensivity Reaction

D. Type IV Hypersensivity Reaction

The answer is A. Type I Hypersensitivity Reactions are immediate and cause anaphylaxis. It occurs when an antigen (the allergen….in this case bee venom) attaches to immunoglobulin E (IgE) antibodies. These antibodies are created due to this allergen and attach to the mast cells and basophils. This leads to a system-wide release of inflammatory mediators (histamine and other inflammatory substances). It is important to note a patient must be sensitized (meaning the immune system has seen the allergen before and produced IgE antibodies in response to the allergen). When the person comes into contact with the foreign substance AGAIN (at a later time) the allergen will attach to that previously created IgE antibody on the mast cell. This will lead to a massive release of histamine and other inflammatory substances that will cause anaphylaxis and lead to anaphylactic shock.

3. Anaphylactic shock can occur due to either an immunological or non-immunological cause. Select ALL the CORRECT statements about the differences between an immunological reaction (anaphylactic) and non-immunological reaction (anaphylactoid):

A. “In an immunological reaction (anaphylactic) IgE antibodies are created and they attach to mast cells and basophils.”

B. “An immunological reaction (anaphylactic) requires a patient to be sensitized for anaphylactic shock to occur.”

C. “A non-immunological reaction (anaphylactoid) causes the same reaction as an anaphylactic reaction, but it’s not due to immunoglobulin IgE antibodies.”

D. “Some common substances that cause a non-immunological reaction (anaphylactoid) are IV contrast  dyes and NSAIDS.”

E. “A patient does not have to be sensitized for a non-immunological reaction (anaphylactoid) to occur and it can happen with first time exposure.”

All the answers are correct: A, B, C, D, E

4. During anaphylactic shock the mast cells and basophils release large amounts of histamine. What effects does histamine have on the body during anaphylactic shock? Select all that apply:

A. Decreases capillary permeability

B. Vasodilation of vessels

C. Decreases heart rate

D. Shifts intravascular fluid to interstitial space

E. Constricts the airways

F. Stimulates contraction of GI smooth muscles

G. Inhibits the production of gastric secretions

H. Itching

The answers are B, D, E, F, and H. Histamine: INCREASES capillary permeability (not decreases) by shifting the intravascular fluid to the interstitial space…this causes swelling and lowers blood pressure, vasodilates vessels…this lower blood pressure and causes red skin, increases heart rate (not decreases), constricts the airway…this causes difficulty breathing and wheezes, stimulates contraction of GI smooth muscles and stimulates (not inhibits) the production of gastric secretions…this leads to vomiting, nausea, and pain, and there is also itching. .

5. You’re providing education to a patient, who has a severe peanut allergy, on how to recognize the signs and symptoms of anaphylactic shock. Select all the signs and symptoms associated with anaphylactic shock:

A. Hyperglycemia

B. Difficulty speaking

C. Feeling dizzy

D. Hypertension

E. Dyspnea

F. Itchy

G. Vomiting and Nausea

H. Fever

I. Slow heart rate

The answers are B, C, E, F, and G. Patients who are in anaphylactic shock will have signs and symptoms associated with the effects of histamine. Remember histamine affects the respiratory, cardiac, GI and skin. The patient can have the following: Respiratory: dyspnea and wheezing (bronchoconstriction), swelling of upper airways due to edema “tightness”…can’t speak, coughing, stuffy nose, watery eyes, Cardiac: tachycardia, hypotension (vasodilation)…loss of consciousness, dizzy, GI: vomiting, nausea, pain, Skin: vasodilation…red, swollen, itchy, hives

6. Your patient is started on an IV antibiotic to treat a severe infection. During infusion, the patient uses the call light to notify you that she feels a tight sensation in her throat and it’s making it hard to breathe. You immediately arrive to the room and assess the patient. While auscultating the lungs you note wheezing. You also notice that the patient is starting to scratch the face and arms, and on closer inspection of the face you note redness and swelling that extends down to the neck and torso. The patient’s vital signs are the following: blood pressure 89/62, heart rate 118 bpm, and oxygen saturation 88% on room air. You suspect anaphylactic shock. Select all the appropriate interventions for this patient:

A. Slow down the antibiotic infusion

B. Call a rapid response

C. Place the patient on oxygen

D. Prepare for the administration of Epinephrine

The answers are B, C, and D. Option A is wrong because the nurse should STOP the infusion, not slow it down because this could be the reason for the anaphylactic reaction. The nurse would want to call a rapid response, place the patient on oxygen, and prepare for the administration of Epinephrine. This drug is the first-line treatment for anaphylactic shock. It will increase the blood pressure, decrease swelling, and dilate the airway.

7. A patient is in anaphylactic shock. The patient has a severe allergy to peanuts and mistakenly consumed an eggroll containing peanut ingredients during his lunch break. The patient is given Epinephrine intramuscularly. As the nurse, you know this medication will have what effect on the body?

A. It will prevent a recurrent attack.

B. It will cause vasoconstriction and decrease the blood pressure.

C. It will help dilate the airways.

D. It will help block the effects of histamine in the body.

The answer is C. Epinephrine acts as a vasopressor and will actually dilate the airway. Epinephrine performs vasoconstriction which will INCREASE the blood pressure. It does not prevent a recurrent attack (corticosteroids may help with this), and it does not block the effects of histamine (antihistamine helps with this).

8. You’re providing care to a patient in anaphylactic shock. What is NOT a typical medical treatment for this condition, and if ordered the nurse should ask for an order clarification?

A. IV Diphenhydramine

B. Epinephrine

C. Corticosteroids

D. Isotonic intravenous fluids

E. IV Furosemide

The answer is E. Furosemide is a loop-diuretic. This medication removes extra fluid from the blood volume. This is NOT used as treatment in anaphylactic shock. Patients with this condition actually need fluids because of the shift of fluid from the intravascular space to the interstitial space. All the other medications may be ordered for this condition depending on the patient’s condition.

9. You’re assessing a patient’s knowledge on how to use their EpiPen in case of an anaphylactic reaction. You’re using an EpiPen trainer device to teach the patient. What demonstrated by the patient shows the patient knows how to administer the medication? Select all that apply:

A. The patient injects the medication in the subq tissue of the abdomen.

B. The patient massages the site after injection.

C. The patient administers the injection through the clothes.

D. The patient aspirates before injecting the medication.

The answers are B and C. EpiPen is an auto-injector that is administered in the middle of outer thigh. It is not given in the abdomen. The patient should massage the site for 10 seconds after administration to increase absorption. It can be administered through clothes, if needed. Aspiration is not required for administration of this medication.

10. What is the MOST important step a nurse can take to prevent anaphylactic shock in a patient?

A. Assessing, documenting, and avoiding all the patient allergies

B. Administering Epinephrine

C. Administering Corticosteroids

D. Establishing IV access

The answer is A. This is the MOST important and easiest step a nurse can take in preventing anaphylactic shock in a patient.

11. A patient is having an anaphylactic reaction to an IV medication. What is the FIRST action the nurse should take?

A. Administer Epinephrine

B. Call a Rapid Reponse

C. Stop the medication

D. Administer a breathing treatment

The answer is C. The FIRST step the nurse should take is to immediately remove the allergen. This would be stopping the medication, and then call a rapid response. The nurse should maintain the airway and start CPR (if needed) until help arrives.

12. What is the BEST position for a patient in anaphylactic shock?

A. Lateral recumbent

B. Supine with legs elevated

C. High Fowler’s

D. Semi-Fowler’s

The answer is B. This position will increase venous return to the heart, which will help increase cardiac output and blood pressure.

More NCLEX Quizzes

Don’t forget to tell your friends about this quiz by sharing it your Facebook, Twitter, and other social media. You can also take more fun nursing quizzes.

*Disclaimer: While we do our best to provide students with accurate and in-depth study quizzes, this quiz/test is for educational and entertainment purposes only. Please refer to the latest NCLEX review books for the latest updates in nursing. This quiz is copyright RegisteredNurseRn.com. Please do not copy this quiz directly; however, please feel free to share a link to this page with students, friends, and others.