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?

Choice A rationale A latex allergy is typically a Type I hypersensitivity reaction (IgE-mediated), involving immediate mast cell degranulation upon exposure. A latex-free environment prevents this IgE-mediated reaction, which is a different immunological mechanism than the Type II cytotoxic hypersensitivity reaction. Choice B rationale A Type II hypersensitivity reaction occurs when antibodies (IgG or IgM) bind to antigens on the surface of specific cells, leading to cellular destruction, such as in a transfusion reaction. Correctly identifying the client and administering the correct type-and-crossmatched blood prevents the binding of preformed anti-A or anti-B antibodies to incompatible red blood cell antigens. Choice C rationale A positive Tuberculosis (TB) skin test is a classic example of a Type IV delayed hypersensitivity reaction (T-cell mediated), which manifests 48-72 hours after antigen exposure. Administering steroids would treat the associated inflammation but does not relate to preventing the Type II cytotoxic mechanism. Choice D rationale "Keeping the client free of the offending agent" is a general principle for preventing all types of hypersensitivity reactions. However, for a Type II reaction, the most common and critical preventable exposure in a hospital setting is to incompatible blood antigens during a transfusion, making the specific action of checking identification the best answer.