Ch. 13
A nurse is administering mycophenolate mofetil as a part of triple immunosuppressive therapy for a posttransplant patient. Which is the most important nursing intervention? 1 Give large doses as intravenous (IV) bolus. 2 Reconstitute the drug in normal saline. 3 Administer the drug over 2 or more hours. 4 Educate the patient about gastrointestinal side effects.
Correct3 The most important nursing intervention when administering mycophenolate mofetil is to infuse this medication over 2 or more hours. Giving the drug slowly helps to decrease the side effects. The drug should never be given as an IV bolus and should always be reconstituted in D5W. Thereafter, the nurse may educate the patient about the gastrointestinal side effects.
A parent brought his or her child to the allergist office for skin testing for suspected allergies. The child is crying, and the parent is fidgeting while trying to comfort the child. What is the most likely cause of anxiety in the parent? 1 The child is hungry. 2 The parent is late for work. 3 Concern about pain from the skin test. 4 The parent is concerned about the child disturbing others in the waiting room.
Correct3 The possible pain the child is about to experience is a likely cause of the parent's anxiety. There is no information in the question to suggest the child is hungry, the parent is late to work, or the child disturbing others in the waiting room.
A nurse is caring for a patient with systemic lupus erythematosus. What is the pathophysiologic response that the disease has on the patient? 1 Autoimmunity 2 Hypersensitivity 3 Immunodeficiency 4 Delayed hypersensitivity
Correct 1 Autoimmunity occurs when the body identifies self proteins as foreign substances and causes cellular and tissue damage. Hypersensitivity is an exaggerated immune response to specific products. Immunodeficiency results from an incompetent immune system, which can be caused by pathogens, medications, and many other factors. Delayed hypersensitivity is a type of hypersensitivity reaction that takes 24 to 48 hours to occur.
Which type of immunity is present at birth? 1 Active 2 Innate 3 Passive 4 Acquired
Correct2 Innate immunity is present at birth. Passive immunity results from the introduction of antibodies from another organism, as in from a mother to her fetus. Acquired immunity can be either passive or active. Active immunity is the result of exposure to a pathogen in order to develop immunity to it, as in the case of vaccination.
Which statement made by the nurse is most appropriate in teaching patient interventions to minimize the effects of seasonal allergic rhinitis? 1 "You will need to get rid of your pets." 2 "You should sleep in an air-conditioned room." 3 "You would do best to stay indoors during the winter months." 4 "You will need to dust your house with a dry feather duster twice a week."
Correct2 Seasonal allergic rhinitis most commonly is caused by pollens from trees, weeds, and grasses. Airborne allergies can be controlled by sleeping in an air-conditioned room, daily damp dusting, covering the mattress and pillows with hypoallergenic covers, and wearing a mask outdoors. It is not necessary to get rid of pets because pet dander does not contribute to seasonal allergies. It is not necessary to stay indoors during the winter. Daily damp dusting is recommended, not dry feather dusting.
A nurse is caring for a patient who is undergoing plasmapheresis for glomerulonephritis. The nurse should be observant for which symptoms indicating citrate toxicity? 1 Sneezing 2 Headache 3 Hypertension 4 Conjunctivitis
Correct2 When caring for a patient undergoing plasmapheresis, the nurse should be observant for headache. Citrate toxicity is a common complication of plasmapheresis because citrate is used as an anticoagulant and may cause hypocalcemia, which in turn manifests as headache, paresthesias, and dizziness. Another common complication of plasmapheresis is hypotension caused by a vasovagal reaction or transient volume changes. Sneezing and conjunctivitis are not manifestations of citrate toxicity but are common symptoms of allergy.
A patient underwent a kidney transplant 24 hours ago. For which type of organ transplant rejection should the nurse closely monitor the patient? 1 Acute 2 Chronic 3 Hyperacute 4 Major histocompatibility antigen
Correct3 A hyperacute rejection occurs within 24 hours because the blood vessels are rapidly destroyed. A chronic rejection is a process that occurs over months or years. Major histocompatibility antigens are responsible for rejections; they are not rejections themselves. An acute rejection most commonly manifests in the first six months after a transplant.
The nurse is administering tracolimus to a patient. What education regarding this medication should the nurse be sure to include during treatment? 1 Take this medication on an empty stomach. 2 This medication has very few side effects. 3 Avoid eating or drinking products with grapefruits. 4 Flu-like symptoms will develop in the first few days after treatment.
Correct3 A substance in grapefruit and grapefruit juice prevents metabolism of these drugs. Consuming grapefruit or grapefruit juice while using tacrolimus could increase their toxicity. There is no specification that the medication should be taken on an empty stomach. The medication does have side effects and includes nephrotoxicity that the patient should be educated regarding. A flu-like syndrome occurs during the first few days of treatment because of cytokine release when taking monoclonal antibodies, not tacrolimus.
A patient has taken amoxicillin once as a child for an ear infection. When given an injection of Penicillin V, the patient develops a systemic anaphylactic reaction. What manifestations would be seen first? 1 Dyspnea 2 Dilated pupils 3 Itching and edema 4 Wheal-and-flare reaction
Correct3 A systemic anaphylactic reaction starts with edema and itching at the site of exposure to the antigen. Shock can develop rapidly with rapid, weak pulse, hypotension, dilated pupils, dyspnea, and possible cyanosis. The wheal-and-flare reaction occurs with a localized anaphylactic reaction, such as a mosquito bite.
What is the role of an antigen in the immune system? 1 To provide immunity 2 To promote homeostasis 3 To elicit an immune response 4 To protect the body against microorganisms
Correct3 An antigen is a substance that elicits an immune response. Antigens do not provide immunity or promote homeostasis. An antigen does not directly protect the body; instead, it stimulates the immune system to produce antibodies.
Which medication is used to treat multiple chemical sensitivity (MCS) disorder? 1 Psychotherapy 2 ACE inhibitors 3 Anxiety-reducing drugs 4 Calcium channel blockers
Correct3 Anxiety-reducing drugs are used to treat MCS disorder. Psychotherapy is used to treat MCS disorder, but it is not itself a medication. ACE inhibitors and calcium channel blockers are used to treat cardiac disorders.
A nurse is conducting a new patient admission assessment. The patient reports having allergies to eggs, nuts, and latex. What is the priority action by the nurse? 1 Place an Epi-Pen at the patient's bedside. 2 Obtain an order for a consult with the dietician. 3 Document the allergies in the patient's medical record. 4 Notify the primary health care provider of the patient's allergies.
Correct3 Because health professionals wear latex gloves when caring for patients, the nurse should first document any allergies in the patient's medical record so that the information is available to all health care providers. Following that, the nurse can also report this information to the primary healthcare provider. Placing an Epi-Pen at the bedside is not appropriate at this time. The nurse does not yet have enough information to determine if the patient should consult a dietitian. Test-Taking Tip: Sometimes the reading of a question in the middle or toward the end of an exam may trigger your mind with the answer or provide an important clue to an earlier question.
The nurse is teaching a group of adults about immunoglobulins. What is the function of IgG? 1 Primary immune response 2 Lining mucous membranes 3 Secondary immune response 4 Causing an allergic response
Correct3 IgG is responsible for the secondary immune response. IgM is responsible for the primary immune response. IgA lines mucous membranes. IgE is responsible for causing allergic reactions.
Where are lymphocytes produced? 1 Spleen 2 Tonsils 3 Bone marrow 4 Thymus gland
Correct3 Lymphocytes are produced in the bone marrow. The spleen is a peripheral lymph organ and is the primary site for filtering foreign antigens from the blood. The thymus gland is involved in the differentiation and maturation of T lymphocytes. The tonsils are a peripheral lymphoid organ.
What is the Uniform Anatomical Gift Act responsible for? 1 Procurement of donor organs 2 Maintaining the organ donor registry 3 Fair and consistent organ transplant laws 4 Length of time a patient is on a transplant list
Correct3 The Uniform Anatomical Gift Act is responsible for fair and consistent transplant laws among all states. There are multiple reasons a patient may be on a transplant list, so the length of time can be attributed to other factors. The division of Organ Procurement and Transplant Network regulated by the US Department of Health and Human Services maintains the organ donor registry. The Uniform Anatomical Gift Act is not responsible for the actual procurement of the donor's organs.
Which nursing interventions should be implemented when caring for a patient who is taking immunosuppressive therapy? Select all that apply. 1 Place the patient in a private room 2 Advise the patient to avoid people who are sick 3 Encourage the patient to reduce daily fluid intake 4 Encourage consumption of fresh fruits and vegetables 5 Advise the patient to report any symptoms of acute illness
Correct 1, 2, 5 The patient should be placed in a private room and be advised to avoid people who are sick. The patient should also report any symptoms of acute illness. The consumption of fresh fruits and vegetables may introduce pathogens to the patient; this action should be discouraged. Encouraging the patient to reduce his or her daily fluid intake is not advised unless otherwise indicated, because the patient needs the fluid intake for adequate perfusion and kidney function.
Which organs contain lymphoid tissue and are considered central or peripheral organs of the immune system? Select all that apply. 1 Skin 2 Heart 3 Kidneys 4 Lymph nodes 5 Bronchial tissue 6 Gastrointestinal tract
Correct 1, 4, 5, 6 The lymph nodes, bronchial tissue, skin, and gastrointestinal tract contain lymphoid tissue and are considered central or peripheral organs of the immune system. The kidneys and heart are not considered central or peripheral immune system organs.
Which functions does the nurse know are part of the normal immune response? Select all that apply. 1 Sepsis 2 Defense 3 Mobilization 4 Surveillance 5 Homeostasis
Correct 2, 4, 5 The functions of the normal immune response include defense, homeostasis, and surveillance. Sepsis is the result of a serious infection, and mobilization is not part of the normal immune response.
A nursing instructor asks a student to identify the central lymphoid organs. Which are correct examples provided by the student nurses? Select all that apply. 1 Spleen 2 Tonsils 3 Lymph nodes 4 Bone marrow 5 Thymus gland
Correct 4, 5 Primary lymphoid organs are those where lymphocytes are formed and matured. The central lymphoid organs include the bone marrow and thymus gland. The spleen, tonsils, and lymph nodes are peripheral lymphoid organs. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking and look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; and (3) Narrow the choices by immediately eliminating answers you know are incorrect.
A nursing instructor is lecturing on immunoglobulins. Which common immunoglobulin would the students expect to find in tears and colostrum? 1 IgE 2 IgA 3 IgG 4 IgM
Correct2 IgA is present in tears and colostrum. IgE and IgG are present in plasma and interstitial fluids. IgM is present in plasma.
The nurse is caring for a group of patients, and one of the patients will be receiving interferon. What type of disease does the nurse determine the patient is being treated for? 1 As a treatment for multiple sclerosis 2 As a treatment for multiple myeloma 3 As a treatment for hairy cell leukemia 4 As a treatment for renal cell carcinoma
Correct1 β-Interferon is used in treating multiple sclerosis. Cytokines instruct cells to alter their proliferation, differentiation, secretion, or activity. Cytokines play an important role in hematopoiesis. α-interferon is used to treat multiple myeloma, hairy cell leukemia, and renal cell carcinoma.
The nurse is monitoring a patient who has a past history of blood transfusion reactions. What hypersensitivity reaction does the nurse determine this patient is at risk for? 1 Type I: IgE-mediated 2 Type II: Cytotoxic 3 Type III: Immune-complex. 4 Type IV: Delayed hypersensitivity.
Correct2 A classic type II reaction occurs when a recipient receives ABO-incompatible blood from a donor. An example of a Type I-IgE-mediated reaction would be anaphylaxis. A Type III reaction would be seen more with autoimmune disorders (such as systemic lupus erythematosis). A Type IV reaction is contact dermatitis.
A nurse has just been asked by a friend to administer allergy shots at home to save money by avoiding office visits. Which response by the nurse is most appropriate? 1 "I would, but it is illegal for nurses to administer injections outside of a medical setting." 2 "These injections should only be administered in a setting where emergency equipment and drugs are available." 3 "Just make sure you have epinephrine in an injectable syringe provided along with the allergy injections." 4 "Allergy shots are not usually effective; it is safer and more effective to control allergies by avoiding allergens."
Correct2 Anaphylactic reactions occur suddenly in hypersensitive patients after exposure to the offending allergen. They may occur after parenteral injection of drugs (especially antibiotics) or blood products, and after insect stings. The cardinal principle in management is speed in recognition of signs and symptoms of an anaphylactic reaction, maintenance of a patent airway, prevention of spread of the allergen by using a tourniquet, administration of drugs, and treatment for shock. The reasoning isn't because it is illegal or because the allergy shots are not effective and the patient needs more than just epinephrine available.
The nurse is teaching a patient with a newly diagnosed latex allergy about foods that may result in latex-food syndrome. Which foods should the patient be taught to avoid? 1 Plums, liver, peas 2 Bananas, kiwis, tomatoes 3 Cashews, oranges, green beans 4 Wax beans, Bing cherries, spinach
Correct2 Foods containing proteins similar to the rubber proteins in latex include bananas, kiwis, tomatoes, avocados, chestnuts, water chestnuts, guavas, hazelnuts, potatoes, peaches, grapes, and apricots. Wax beans, Bing cherries, spinach, plums, liver, peas, cashews, oranges, and green beans do not pose a risk for patients with latex allergy.
The nurse is providing education to a patient with a recent organ transplant and is discussing immunosuppressive therapy. What statement made by the patient indicates that teaching has the desired outcome? 1 "Taking more than one medication will put me at risk for developing allergies." 2 "My drug dosages will be lower because the medications enhance each other." 3 "I will be more prone to malignancies because I will be taking more than one drug." 4 "The lower doses of my medications can prevent rejection and minimize the side effects."
Correct4 Because immunosuppressants work at different phases of the immune response, lower doses of each drug can be used to produce effective immunosuppression while minimizing side effects. The use of several medications is not because they enhance each other, and does not increase the risk of allergies or malignancies.
A patient has a latex allergy caused by chemicals that are used in manufacturing of the gloves used in hospitals. What type of allergy does the nurse educate the patient about? 1 Type I 2 Type II 3 Type III 4 Type IV
Correct4 Contact dermatitis caused by the chemicals used in the manufacturing process of latex gloves is a type IV hypersensitivity reaction. It is a delayed reaction. It occurs within 6 to 48 hours. Type II and Type III are not types of latex allergies. A Type I allergic reaction is related to the natural rubber latex proteins and occurs within minutes of contact with the proteins.
What is the primary function of interferon-beta? 1 Proliferation and differentiation of monocytes 2 Proliferation and differentiation of neutrophils 3 Production of red blood cells in the bone marrow 4 Activation of natural killer cells and macrophages
Correct4 Interferon-beta activates natural killer cells, inhibits viral replication, and has antiproliferative effects on tumor cells. Granulocyte-macrophage colony-stimulating factor (GM-CSF) is responsible for the proliferation and differentiation of monocytes. G-CSF stimulates the proliferation and differentiation of neutrophils. Production of red blood cells in the bone marrow is the function of erythropoietin. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect.
A patient with chronic myelogenous leukemia has an overabundance of white blood cells (WBC). What procedure should the nurse prepare to educate the patient about? 1 Apheresis 2 Plateletpheresis 3 Plasmapheresis 4 Leukocytapheresis
Correct4 Leukocytapheresis is a process that involves removal of white blood cells from the body. In cases of chronic myelogenous leukemia, this technique involves removal of leukemic cells. Separation of blood components followed by isolation of one or more components is called apheresis. Plateletpheresis is separation of platelets from the blood. Plasmapheresis involves separation of plasma from whole blood. Test-Taking Tip: Multiple-choice questions can be challenging because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.
Ten days after receiving a bone marrow transplant, a patient develops a skin rash on the palms of the hand and soles of the feet, jaundice, and diarrhea. What does the nurse suspect is occurring with this patient? 1 The patient is experiencing a type I allergic reaction. 2 An atopic reaction is causing the patient's symptoms. 3 The patient is experiencing rejection of the bone marrow. 4 Cells in the transplanted bone marrow are attacking the host tissue.
Correct4 The patient's symptoms are characteristic of graft-versus-host-disease (GVHD) in which transplanted cells mount an immune response to the host's tissue. GVHD is not a type I allergic response or an atopic reaction, and it differs from transplant rejection in that the graft rejects the host rather than the host rejecting the graft.
Which type of immunity causes the rejection of transplanted tissue? 1 Innate 2 Humoral 3 Acquired 4 Cell-mediated
Correct4 The rejection of transplanted tissue is an example of a cell-mediated immune response. The immune response occurs with a specific recognition by T cells. Innate immunity is present at birth. Humoral immunity is an antibody immunity. Acquired immunity is the development of immunity.
The nurse differentiates between the types of hypersensitivity reactions and recognizes that which type is related to cell-mediated immunity? 1 Type I 2 Type II 3 Type III 4 Type IV
Correct4 Type IV is related to cell-mediated immunity. It is a delayed hypersensitivity reaction. Tissue damage occurs in delayed hypersensitivity reactions. It requires 24 to 48 hours for a response to occur. Type I, Type II, and Type III are immediate reactions and are a part of humoral immunity.