The nurse cares for clients in the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction.

Choice A rationale Administering steroids is a treatment for certain inflammatory or autoimmune conditions, but it does not prevent a type II hypersensitivity reaction. A positive tuberculin skin test (TB test) indicates a type IV (delayed) hypersensitivity, which is a different immune mechanism than the type II (cytotoxic) reaction. This action is unrelated to preventing type II reactions. Choice B rationale Type II hypersensitivity reactions, such as a hemolytic transfusion reaction, occur when antibodies (IgG or IgM) bind to antigens on the surface of specific cells, leading to cell lysis. Correctly identifying the client before a blood transfusion ensures that the client receives compatible blood, preventing the recipient's antibodies from attacking the donor's red blood cells. Choice C rationale Avoiding tree nuts is a crucial intervention to prevent a Type I hypersensitivity reaction (immediate hypersensitivity or allergy), which is mediated by IgE antibodies and mast cell degranulation. This mechanism is distinct from a Type II cytotoxic reaction, which involves antibodies binding directly to cell surface antigens. Choice D rationale Providing a latex-free environment is an essential measure to prevent a latex allergy, which can manifest as either a Type I (immediate) hypersensitivity or a Type IV (delayed) hypersensitivity (contact dermatitis), depending on the specific mechanism. It is not the primary intervention for preventing a Type II cytotoxic reaction.