The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction?
a. Administering steroids for severe serum sickness
b. Correctly identifying the client prior to a blood transfusion
c. Keeping the client free of the offending agent
d. Providing a latex-free environment for the client
ANS: B
A classic example of a type II hypersensitivity reaction is a blood transfusion reaction. These can be prevented by correctly identifying the client and cross-checking the unit of blood to be administered. Serum sickness is a type III reaction. Avoidance therapy is the cornerstone of treatment for a type IV hypersensitivity. Latex allergies are a type I hypersensitivity.
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