Chapter 48 & 49: Immunosuppressant Drugs

The nurse is reviewing principles of immunization. What type of immunization occurs when antibodies pass from mother to infant during breastfeeding or through the placenta during pregnancy? a. Artificial active immunization b. Attenuating immunization c. Natural passive immunization d. Artificial passive immunization

ANS: C Natural passive immunization occurs when antibodies are transferred from the mother to her infant in breast milk or through the bloodstream via the placenta during pregnancy. Artificial active immunization causes an antigen-antibody response and stimulates the body's defenses to resist any subsequent exposures. Passive immunization is conferred by bypassing the host's immune system and injecting the person with antiserum or concentrated antibodies obtained from other humans or animals; this gives the host direct means of fighting off an invading microorganism. The host's immune system therefore does not have to manufacture these antibodies.

A sanitation worker has experienced a needle stick by a contaminated needle that was placed in a trash can. The employee health nurse expects that which drug will be used to provide passive immunity to hepatitis B infection? a. Haemophilus influenzae type b (Hib) b. Varicella virus vaccine (Varivax) c. Hepatitis B immunoglobulin (BayHep B) d. Hepatitis B virus vaccine (inactivated) (Recombivax HB)

ANS: C Recombivax HB promotes active immunity to hepatitis B infection in people who are considered to be at high risk for potential exposure to the virus, whereas hepatitis B immunoglobulin provides passive immunity for the prophylaxis and postexposure treatment of people exposed to hepatitis B virus or HBs-Ag-positive materials, such as blood, plasma, or serum. Hib and Varivax vaccines are not appropriate for this situation.

Two patients arrive at the clinic; one is a young boy with sickle cell anemia, and another is a 57-year-old woman with early stages of Hodgkin's disease. The nurse notices that both patients need the same vaccine. What vaccine would that be? a. Varicella virus vaccine (Varivax) b. Herpes zoster vaccine (Zostavax) c. Hepatitis B virus vaccine, inactivated (Recombivax HB) d. Haemophilus influenzae type b (Hib) vaccine

ANS: D H. influenzae type b conjugate vaccine is usually given to patients with one of these disorders: sickle cell anemia, an immunodeficiency syndrome, Hodgkin's disease, and others. The other options are incorrect.

Cyclosporine is prescribed for a patient who had an organ transplant. The nurse will monitor the patient for which common adverse effect? a. Nausea and vomiting b. Fever and tremors c. Agitation d. Hypertension

ANS: D Moderate hypertension may occur in as much as 50% of patients taking cyclosporine. The other options are potential adverse effects of other immunosuppressant drugs.

The nurse is preparing to administer an injection of monoclonal antibodies. Which additional drug will the nurse administer to minimize adverse reactions to the monoclonal antibodies? a. A nonsteroidal anti-inflammatory drug b. A benzodiazepine c. An opioid pain reliever d. A corticosteroid

ANS: D The monoclonal antibodies basiliximab and daclizimab have a tendency to cause the allergy-like reaction known as cytokine release syndrome, which can be severe and even involve anaphylaxis. In an effort to avoid or alleviate this problem, it is recommended that an injection of a corticosteroid, such as methylprednisolone, be administered before the injection of monoclonal antibodies.

A patient has an order for cyclosporine (Sandimmune). The nurse finds that cyclosporine-modified (Neoral) is available in the automated medication cabinet. Which action by the nurse is correct? a. Hold the dose until the prescriber makes rounds. b. Give the cyclosporine-modified drug. c. Double-check the order, and then give the cyclosporine-modified drug. d. Notify the pharmacy to obtain the Sandimmune form of the drug.

ANS: D The nurse must double-check the formulation before giving cyclosporine. Cyclosporine-modified products (such as Neoral or Gengraf) are interchangeable with each other but are not interchangeable with Sandimmune. In this case, the nurse must obtain the Sandimmune form of the drug from the pharmacy. The other options are incorrect.

15. Mr. S. brings his toddler, Carl, in for a 12-month well-child checkup. Before the nurse gives the measles, mumps, and rubella (MMR) vaccine injection, what adverse effects will she tell Mr. S. to watch for in Carl's response to the immunization? What can be done to relieve these adverse effects?

Carl may experience localized swelling, redness, discomfort, and warmth at the injection site. Acetaminophen and rest are recommended for the relief of these side effects, and application of warm compresses to the injection site may also help ease some of the discomfort.

A 30-year-old woman is in the clinic for her yearly gynecologic exam and asks the nurse about the "new vaccine that prevents HPV." She wants to receive the papillomavirus vaccine (Gardasil). Which response by the nurse is most appropriate? a. "For women, the recommended age for this vaccine is 13 to 26 years of age." b. "We will need to make sure you are not pregnant first." c. "There will be a total of three injections." d. "I will check with your health care provider and then get the first dose of the vaccine ready."

ANS: A It is important to make sure that a patient receiving Gardasil is not pregnant and that the patient knows that there are a total of three injections, but this particular patient is too old to receive the vaccine. The guidelines recommend the vaccine for women 13 to 26 years of age.

The nurse is monitoring a patient who is receiving muromonab-CD3 (Orthoclone OKT3) after an organ transplant. Which effect is possible with muromonab-CD3 therapy? a. Chest pain b. Hypotension c. Confusion d. Dysuria

ANS: A Muromonab-CD3 may cause chest pain, fever, chills, tremor, gastrointestinal disturbances (nausea, vomiting, diarrhea), and other effects as noted in Table 48-2. The other options are incorrect.

A 45-year-old man has received a series of immunizing drugs in preparation for a trip to a developing country. Within hours, his wife brings him to the emergency department because he has developed edema of the face, tongue, and throat and is having trouble breathing. The nurse suspects that, based on the patient's history and symptoms, he is experiencing which condition? a. Serum sickness b. Cross-sensitivity c. Thrombocytopenic purpura d. Adenopathy

ANS: A Serum sickness sometimes occurs after repeated injections of equine (horse)-made immunizing drugs and is characterized by edema of the face, tongue, and throat; rash; urticaria; fever; flushing; dyspnea; and other symptoms.

A patient is about to undergo a kidney transplant. She will be given an immunosuppressant drug before, during, and after surgery to minimize organ rejection. During the preoperative teaching session, which information will the nurse include about the medication therapy? a. Several days before the surgery, the medication will be administered orally. b. The oral doses need to be taken 1 hour before meals to maximize absorption. c. Mix the oral liquid with juice in a disposable Styrofoam cup just before administration. d. Intramuscular injections of the medication will be needed for several days preceding surgery.

ANS: A Several days before transplant surgery, immunosuppressant drugs need to be taken by the oral route, if possible, to avoid intramuscular injections and the risk for infection caused by the injections. Avoid Styrofoam containers because the medication may adhere to the side of the container. These medications are taken with food to minimize gastrointestinal upset.

The nurse is reviewing the information about the herpes zoster vaccine (Zostavax) before administering the dose. Which statements about the vaccine are true? (Select all that apply.) a. It is a one-time vaccine. b. The vaccine is recommended for patients 50 years of age and older. c. The vaccine is given to children to prevent chickenpox. d. It is used to prevent postherpetic neuralgia. e. It is contraindicated in patients who have already had shingles. f. The vaccine is used to prevent reactivation of the zoster virus that causes shingles.

ANS: A, B, F Zoster vaccine (Zostavax) is used to prevent shingles; it also prevents reactivation of the zoster virus that causes shingles. It is given to patients 50 years of age and older, and it is a one-time vaccine. It is not given to prevent chickenpox or given to children. It does not prevent postherpetic neuralgia, and it can be given to patients who have already had shingles.

The nurse is reviewing the health history of a new patient who may need immunizations. Active immunizations are usually contraindicated in which patients? (Select all that apply.) a. Patients with a febrile illness b. Children younger than 1 year of age c. Elderly patients d. Patients who are immunosuppressed e. Those receiving cancer chemotherapy

ANS: A, D, E Contraindications to the administration of immunizing drugs include a history of reactions to or serious adverse effects resulting from the drugs, and patients who are already immunosuppressed (patients with AIDS and patients receiving chemotherapy). Immunizations are best deferred until after a febrile illness. Children younger than 1 year of age and the

A patient is in the urgent care center after experiencing a black widow spider bite. The nurse prepares to give which product to treat this injury? a. Live vaccine b. Antivenins or antisera c. Tetanus immune globulin d. Active immunizing drug

ANS: B Antivenins, also known as antisera, are used to prevent or minimize the effects of poisoning by poisonous snakes and spiders. They provide the person who has been bitten with the substance needed to overcome the effects of the venom.

A 12-month-old infant has received an MMR II (measles, mumps, and rubella virus vaccine), and her mother calls the clinic that afternoon to ask about helping her fussy infant to "feel better." What will the nurse suggest? a. Apply an ice pack to the injection site. b. Apply warm compresses to the injection site. c. Observe the site for further swelling and redness. d. Bring the infant in to the emergency department for an immediate examination.

ANS: B Applying warm compresses to the injection site and using acetaminophen (not aspirin, which carries the risk for Reye's syndrome) should help to relieve the discomfort. The other options are incorrect.

A patient must be treated immediately for acute organ transplant rejection. The nurse anticipates that muromonab-CD3 (Orthoclone OKT3) will be ordered. What is the priority assessment before beginning drug therapy with muromonab-CD3? a. Serum potassium level b. Fluid volume status c. Electrocardiogram d. Blood glucose level

ANS: B Assess fluid volume status because muromonab-CD3 is contraindicated in the presence of fluid overload. The other options are incorrect.

A patient with multiple sclerosis will be starting therapy with an immunosuppressant drug. The nurse expects that which drug will be used? a. Azathioprine (Imuran) b. Glatiramer acetate (Copaxone) c. Daclizumab (Zenapax) d. Sirolimus (Rapamune)

ANS: B Glatiramer acetate and fingolimod are the only immunosuppressants currently indicated for reduction of the frequency of relapses (exacerbations) in a type of multiple sclerosis known as relapsing-remitting multiple sclerosis.

When monitoring a patient who is on immunosuppressant therapy with azathioprine (Imuran), the nurse will monitor which laboratory results? a. Serum potassium levels b. White blood cell (leukocyte) count c. Red blood cell count d. Serum albumin levels

ANS: B Leukopenia is a potential adverse effect of azathioprine therapy, so white blood cells need to be monitored. The other options are incorrect.

When administering cyclosporine, the nurse notes that allopurinol is also ordered for the patient. What is a potential result of this drug interaction? a. Reduced adverse effects of the cyclosporine b. Increased levels of cyclosporine and toxicity c. Reduced uric acid levels d. Reduced nephrotoxic effects of cyclosporine

ANS: B The allopurinol may cause increased levels of cyclosporine, and toxicity may result. The other options are incorrect.

A nurse is working in an immunization clinic. A new colleague asks, "When is the first dose of the diphtheria, tetanus, and acellular pertussis (DtaP, Daptacel) given?" The nurse knows that this series is started at what age? a. At birth b. 6 weeks c. 3 months d. 1 year

ANS: B The first dose of the series of three injections is given at 6 weeks of age. The other options are incorrect.

A patient has started azathioprine (Imuran) therapy as part of renal transplant surgery. The nurse will monitor for which expected adverse effect of azathioprine therapy? (Select all that apply.) a. Tremors b. Leukopenia c. Diarrhea d. Thrombocytopenia e. Hepatotoxicity f. Fluid retention

ANS: B, D, E Leukopenia is an expected adverse effect of azathioprine therapy, as are thrombocytopenia and hepatotoxicity. The other options are incorrect.

The nurse follows which procedures when giving intravenous (IV) cyclosporine? (Select all that apply.) a. Administering it as a single IV bolus injection to minimize adverse effects b. Using an infusion pump to administer this medication c. Monitoring the patient for potential delayed adverse effects, which may be severe d. Monitoring the patient closely for the first 30 minutes for severe adverse effects e. Checking blood levels periodically during cyclosporine therapy f. Performing frequent oral care during therapy

ANS: B, D, E, F Cyclosporine is infused intravenously with an infusion pump, not as an IV bolus. Monitor the patient closely for the first 30 minutes for adverse effects, especially for allergic reactions, and monitor blood levels periodically to ensure therapeutic, not toxic, levels of the medication. Perform oral hygiene frequently to prevent dry mouth and subsequent infections.

14. Mrs. T., an 82-year-old widow, is in the office for a follow-up appointment to evaluate her emphysema. The physician recommends that she have an influenza virus vaccine. As the nurse prepares the injection, Mrs. T. says, "I had a flu shot last year—why do I need another one this year?" What is the nurse's explanation to her?

Each year a new influenza vaccine is developed that contains three influenza virus strains that represent the strains most likely to circulate in the United States in the upcoming winter. The vaccination from the previous year may not be effective for the influenza virus strains occurring in the current year.

12. A patient on cyclosporine therapy is convinced that the cyclosporine is upsetting his stomach. What can be done to alleviate this problem?

Encourage the patient to take the drug with meals or mixed with chocolate milk, milk, or orange juice to prevent stomach upset.

15. John has relapsing-remitting multiple sclerosis and is in the hospital because of an acute exacerbation. The physician talks to him about a "different type" of therapy with an immunosuppressant drug. What drug will be used, and how can it help John?

Fingolimod (Gilenya) and glatiramer acetate (Copaxone) are immunosuppressants that are indicated for reduction of the frequency of relapses (exacerbations) in a type of multiple sclerosis known as relapsing-remitting multiple sclerosis.

17. Paul has received several immunizations in preparation for an overseas trip. He expected to feel some soreness at the injection sites, but the next morning, he wakes up with swelling of the face and tongue, difficulty breathing, shortness of breath, nausea and vomiting, and a fever of 102° F (38.9° C). What is happening, and what should he do?

Paul is experiencing more than the expected adverse effects of his vaccinations. He is probably experiencing "serum sickness," which may occur after repeated injections of equine-derived immunizing drugs. Because his symptoms may indicate respiratory impairment, he needs to be taken to the hospital for evaluation and monitoring; he needs to call 911 rather than try to drive himself to the hospital. He may receive analgesics, antihistamines, epinephrine, or corticosteroids (or a combination of these drugs) to treat this reaction.

12. Emily, age 25 years, has stepped on a rusty piece of metal and will be receiving a tetanus booster after the wound is cleansed and stitched. Her last tetanus booster, a Td, was 10 years ago. Which booster is she likely to receive today? Explain your answer.

She will most likely receive the DTaP (diphtheria, tetanus, and acellular pertussis vaccine [Adacel]). With the recent increase in cases of pertussis, DTaP is recommended for adults in place of tetanus-diphtheria, which lacks the pertussis component.

13. Jim, a cabinetmaker, is cut by a woodworking tool and comes to the clinic for stitches. When the nurse asks him about his tetanus vaccination history, he says, "I have no idea when my last tetanus shot was—I thought that once I had all the shots for school, I was set for life! Surely I don't need any more." What will the nurse explain to Jim?

Sometimes, after vaccination, the levels of antibodies against a particular pathogen decline over time, and a second dose of the vaccine is given to restore the antibody titers to a level that can protect the person against the infection. This second dose is referred to as a booster shot.

13. A hospitalized patient has asked the nurse to mix the doses of cyclosporine in his disposable Styrofoam cup with milk before he drinks it. What will the nurse do?

Styrofoam containers or cups should be avoided because the drug has been found to adhere to the inside wall of such containers. The nurse needs to find a glass or cup that is not made of Styrofoam. After the drug is mixed, the patient needs to drink it immediately.

14. Tess has had a renal transplant. She is being given muromonab-CD3 intravenously, 5 mg/day in a single bolus. On the second day, she begins to exhibit chest pain, dyspnea, and wheezing. What is happening? What does the nurse need to do at this time? What can be ordered to reduce these problems?

Tess is experiencing symptoms consistent with adverse effects of muromonab-CD3. The nurse will need to monitor her closely for signs of fluid retention and pulmonary edema and for an allergy-like reaction known as cytokine release syndrome, which can be severe. Patients are often premedicated with corticosteroids (e.g., intravenous methylprednisolone) in an effort to avoid or alleviate this problem.

16. There have been news reports about anthrax threats. Your neighbor is worried and asks you which type of anthrax is the most deadly. What does he mean by "which type," and what is the answer to his question?

There are three types of anthrax based on the routes of inoculation: cutaneous, inhalational, and gastrointestinal. Of the three, anthrax contracted by inhalation of the bacterial spores is the most deadly and has a mortality rate of more than 80%.

4. When teaching patients who are taking oral doses of immunosuppressants, how will the nurse instruct the patient to take the medication? a. With food to minimize gastrointestinal upset b. On an empty stomach to increase the absorption rate c. Only when adverse effects are tolerable d. Mixed with water only

a

5. The nurse is preparing to give a second dose of DTaP vaccine to a 6-month-old infant. The infant's mother tells the nurse that the last time he received this vaccination, the injection site on his leg became warm and slightly reddened. Which is the nurse's best action? a. Explain that these effects can be expected and give the medication. b. Give half the prescribed dose this week and the other half next week if tolerated well. c. Skip the dose and notify the physician. d. Wait 6 months and then administer the dose.

a

7. The nurse is providing patient teaching to a 24-year-old woman regarding the human papillomavirus (HPV) vaccine. Which statement by the woman indicates that more teaching is needed? (Select all that apply.) a. "This vaccine only takes one injection." b. "I need to have this vaccine before I turn 26." c. "It is safe to get this vaccine if I am pregnant." d. "This vaccination prevents the virus that commonly causes genital warts." e. "My 13-year-old sister should have this vaccine, too."

a c

5. The nurse providing education for patients taking immunosuppressants will include which information? (Select all that apply.) a. The mouth and tongue should be inspected carefully for white patches. b. Allergic reactions to these drugs are rare. c. Patients should avoid crowds to minimize the risk for infection. d. Patients should report any fever, sore throat, chills, or joint pain. e. Patients should take oral forms with food to avoid gastrointestinal upset.

a c d e

8. A patient will be taking cyclosporine after transplant surgery. Which of these are potential adverse effects of cyclosporine therapy? (Select all that apply.) a. Hypertension b. Fever c. Nephrotoxicity d. Fluid retention e. Hypotension f. Posttransplant diabetes mellitus

a c f

7. Which drugs are indicated for the treatment of multiple sclerosis? (Select all that apply.) a. Glatiramer acetate b. Azathioprine c. Basiliximab d. Daclizumab e. Fingolimod

a e

Mrs. F. is about to undergo kidney transplant surgery. The physician plans for her to start taking sirolimus (Rapamune). a. Mrs. F. asks the nurse why she is taking this medication. How will the nurse answer? b. Three days before her surgery, an oral antifungal drug is added to Mrs. F.'s regimen. "Why do I have to take this, too?" she asks. How will the nurse answer?

a. Sirolimus (Rapamune) can help prevent organ rejection. If Mrs. F.'s immune system cannot recognize the new kidney as foreign, it will not mount an immune response against it. This promotes success of the transplant. b. The antifungal drug is added several days before surgery as prophylaxis for oral candidiasis.

1. When monitoring patients on immunosuppressant therapy, the nurse must keep in mind that the major adverse effect for patients taking these drugs is which finding? a. Severe hypotension with potential renal failure b. Increased susceptibility to opportunistic infections c. Decreased platelet aggregation d. Increased bleeding tendencies

b

2. The immunity that is passed from a mother to her nursing infant through antibodies in breast milk is known as which type of immunity? a. Artificially acquired passive immunity b. Naturally acquired passive immunity c. Active immunity d. Genetic immunity

b

6. Which statement correctly describes the method of action of the immunosuppressants? a. These agents inhibit the antigen-antibody relationship. b. These agents suppress the action of T lymphocytes, compromising the immune system. c. These agents inhibit prostaglandins, rendering them ineffective in the immune response. d. These agents alter the ability of the body to manufacture albumin, and cells lose their integrity and die.

b

8. A student nurse was informed of the need for a "booster" injection for hepatitis B. The student asks the health center nurse why another injection is indicated because the series of three injections was completed. Select the nurse's best response. a. "Too much time has elapsed between the second and third injections, and you need a second 'third shot.'" b. "With the three injections, your body did not manufacture enough antibodies, and to be therapeutic, you need another injection." c. "You have an altered immune response and may never be protected from hepatitis B." d. "One of the initial injections you received must have been ineffective."

b

2. A patient is experiencing rejection of a transplanted organ. The nurse expects which drug to be prescribed to manage this? a. Azathioprine b. Cyclosporine c. Muromonab-CD3 d. Glatiramer acetate

c

3. The nurse is discussing drug therapy with cyclosporine. Which food product could possibly increase the activity of cyclosporine? a. Dairy product b. Orange juice c. Grapefruit juice d. Red wine

c

4. When reviewing various immunizing drugs, the nurse recalls that one product is purposefully administered to pregnant women. Which is an example of this type of product? a. Poliovirus vaccine b. Tetanus immune globulin c. RhO(D) immune globulin d. Black widow spider antivenin

c

6. A nurse has been stuck by a used needle while starting an intravenous line. Which preparation is used as prophylaxis against disease after exposure to blood and body fluids? a. Hib vaccine b. RhO(D) immune globulin c. Hepatitis B immune globulin d. Hepatitis antitoxin

c

9. Which of the following statements is true about the zoster vaccine? a. It can be safely administered to immunocompromised patients. b. It requires three doses over 12 months. c. It is indicated for individuals 50 years of age and older. d. It is effective against the chickenpox virus and can be administered to children.

c

3. Which substance contains microorganisms that trigger the formation of antibodies against specific pathogens? a. Antivenin b. Serum c. Toxoid d. Vaccine

d