Organ Transplant

22. After teaching a client who is recovering from pancreas transplantation, the nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? a. "If I develop an infection, I should stop taking my corticosteroid." b. "If I have pain over the transplant site, I will call the surgeon immediately." c. "I should avoid people who are ill or who have an infection." d. "I should take my cyclosporine exactly the way I was taught."

ANS: A Immunosuppressive agents should not be stopped without the consultation of the transplantation physician, even if an infection is present. Stopping immunosuppressive therapy endangers the transplanted organ. The other statements are correct. Pain over the graft site may indicate rejection. Antirejection drugs cause immunosuppression, and the patient should avoid crowds and people who are ill. Changing the routine of antirejection medications may cause them to not work optimally.

24. A nurse has obtained donor tissue typing information about a patient who is waiting for a kidney transplant. Which result should the nurse report to the transplant surgeon? a. The patient-donor crossmatch is positive. b. Six antigen matches are present in HLA typing. c. The patient is Rh positive and donor is Rh negative. d. Panel of reactive antibodies (PRA) percentage is low.

ANS: A Positive cross matching is an absolute contraindication to kidney transplantation because a hyperacute rejection will occur after the transplant. The other information shows that the tissue match between the patient and potential donor is acceptable.

8. A nurse assesses a client who is recovering from a heart transplant. Which assessment findings would alert the nurse to the possibility of heart transplant rejection? (Select all that apply.) a. Shortness of breath b. Abdominal bloating c. New-onset bradycardia d. Increased ejection fraction e. Hypertension f. Fatigue

ANS: A, B, C, F Clinical findings of heart transplant rejection include shortness of breath, fatigue, fluid gain, abdominal bloating, new-onset bradycardia, hypotension, atrial fibrillation or flutter, decreased activity tolerance, and decreased ejection fraction.

17. A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention would the nurse expect for this patient? a. Testing for human leukocyte antigen (HLA) match b. Administration of immunosuppressant medications c. Insertion of an arteriovenous graft for hemodialysis d. Placement of the patient on the transplant waiting list

ANS: B Acute rejection is treated with the administration of additional immunosuppressant drugs such as corticosteroids. Because acute rejection is potentially reversible, there is no sign that the patient will need another transplant or hemodialysis. There is no need to repeat HLA testing.

15. Which information in a patient's history indicates to the nurse that the patient is not an appropriate candidate for kidney transplantation? a. The patient has type 1 diabetes. b. The patient has metastatic lung cancer. c. The patient has a history of chronic hepatitis C infection. d. The patient is infected with human immunodeficiency virus.

ANS: B Advanced cancer is a contraindication to transplantation. The conditions of the other patients are not contraindications for kidney transplant.

18. A nurse is providing discharge teaching to a client recovering from a heart transplant. Which statement would the nurse include? a. "Use a soft-bristled toothbrush and avoid flossing." b. "Avoid large crowds and people who are sick." c. "Change positions slowly to avoid hypotension." d. "Check your heart rate before taking the medication."

ANS: B Clients who have had heart transplants must take immunosuppressant therapy for the rest of their lives. The nurse would teach this client to avoid crowds and sick people to reduce the risk of becoming ill him- or herself. These medications do not place clients at risk for bleeding, orthostatic hypotension, or changes in heart rate. Orthostatic hypotension from the denervated heart is generally only a problem in the immediate postoperative period.

11. A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago. The client states, "I'm having right belly pain and have a temperature of 101° F (38.3° C)." How would the nurse respond? a. "The anti-rejection drugs you are taking make you susceptible to infection." b. "You should go to the hospital immediately to get checked out." c. "You should take an additional dose of cyclosporine today." d. "Take acetaminophen every 4 hours until you feel better soon."

ANS: B Fever, right abdominal quadrant pain, and jaundice are signs of possible liver transplant rejection; the client would be admitted to the hospital as soon as possible for intervention. Antirejection drugs do make a client more susceptible to infection, but this client has signs of rejection, not infection. The nurse would not advise the client to take an additional dose of cyclosporine or acetaminophen as these medications will not treat the acute rejection.

33. The nurse is titrating the IV fluid infusion rate four hours after a patient has had kidney transplantation. Which parameter will be most important for the nurse to consider? a. Heart rate b. Urine output c. Creatinine clearance d. Blood urea nitrogen (BUN) level

ANS: B Fluid volume is replaced based on urine output after transplant because the urine output can be as high as a liter an hour. The other data will be monitored but are not the most important determinants of fluid infusion rate.

15. The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by the patient indicates a need for further instructions? a. "I need to be monitored closely for development of cancer." b. "After a couple of years, I will be able to stop taking immunosuppressants." c. "If I develop an acute rejection episode, I will need additional types of drugs." d. "The drugs are combined to inhibit different ways the kidney can be rejected."

ANS: B Immunosuppressants will need to be continued for life. The other patient statements are accurate and indicate that no further teaching is necessary about those topics.

31. The nurse is assessing a patient 4 hours after a kidney transplant. Which information is most important to communicate to the health care provider? a. The urine output is 900 to 1100 mL/hr. b. The patient's central venous pressure (CVP) is decreased. c. The patient reports level 7 (0- to 10-point scale) incisional pain. d. The blood urea nitrogen (BUN) and creatinine levels are elevated.

ANS: B The decrease in CVP suggests hypovolemia, which must be rapidly corrected to prevent renal hypoperfusion and acute tubular necrosis. The other information is not unusual in a patient after a transplant.

24. A patient with leukemia is considering whether to have hematopoietic stem cell transplantation (HSCT). Which information would the nurse include in the patient's teaching plan? a. Donor bone marrow is transplanted through a sternal or hip incision. b. Protective isolation is required for several weeks after the stem cell transplant. c. The transplant procedure takes place in a sterile operating room to decrease the risk for infection. d. Transplant of the donated cells can be very painful because of the nerves in the tissue lining the bone.

ANS: B The patient requires strict protective isolation to prevent infection for 2 to 4 weeks after HSCT while waiting for the transplanted marrow to start producing cells. The transplanted cells are infused through an IV line so the transplant is not painful, nor is an operating room or incision required.

13. Ten days after receiving a bone marrow transplant, a patient develops a skin rash. Which process would the nurse suspect is causing the rash? a. The patient is showing signs of hyperacute rejection. b. The patient's cells are being attacked by the donor T cell. c. The patient's antibodies are rejecting the donor bone marrow. d. The patient is experiencing a delayed hypersensitivity reaction.

ANS: B The patient's history and symptoms indicate that the patient is experiencing graft-versus-host disease, in which the donated T cells attack the patient's tissues.

65. A 19-year-old male with cystic fibrosis (CF) has a serious lung infection and needs a lung transplant. However, he has a rare blood type that complicates getting a donor organ. He has also been diagnosed with bipolar disorder and treated successfully since mid-adolescence. The client requests to see a chaplain to help him make plans for a funeral and donation of his body to science after death. How should the nurse interpret the client's request? a. depressive side of his bipolar disorder, and he should be checked for suicidal thoughts/plans. b. an exacerbation of the client's CF and warrants further assessment by his lung specialist. c. client's awareness he is likely to have a shortened life span and should be supported by unit staff. d. delirium as a result of the many medications he is taking and requires further assessment by the pharmacist or healthcare provider.

ANS: C A client who has endured serious chronic illness (both psychiatric and medical) would be well aware of his shortened life span, particularly if he is unable to get a lung transplant. It would not be unusual for him to want to plan ahead so his wishes would be honored in the event of his death. In the absence of other physical signs, an exacerbation of CF or delirium is not demonstrated. Likewise, his successful bipolar treatment in the absence of any other signs rules depression out as a reason for his behavior. Though it may be difficult to think about a young person in terms of dying, the client's consideration of the future is a rational decision.

17. A patient who had a kidney transplant eight years ago is receiving the immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), and prednisone. Which assessment data will be of most concern to the nurse? a. Skin is thin and fragile. b. Blood pressure is 150/92. c. A lump is palpable in the axilla. d. Fasting blood glucose is 144 mg/dL.

ANS: C A palpable lump suggests a possible cancer, such as a lymphoma, which could occur as a result of chronic immunosuppressive therapy. The increased glucose, skin change, and hypertension are possible side effects of the prednisone and should be addressed, but they are not as great a concern as the possibility of cancer.

16. Which assessment finding may indicate that a patient is experiencing adverse effects to a corticosteroid taken for four years after kidney transplantation? a. Postural hypotension b. Recurrent tachycardia c. Knee and hip joint pain d. Increased serum creatinine

ANS: C Aseptic necrosis of the weight-bearing joints can occur when patients take corticosteroids over a prolonged period. Increased creatinine level, orthostatic dizziness, and tachycardia are not associated with corticosteroid use.

17. After teaching a client who is recovering from a heart transplant to change positions slowly, the client asks, "Why is this important?" How would the nurse respond? a. "Rapid position changes can create shear and friction forces, which can tear out your internal vascular sutures." b. "Your new vascular connections are more sensitive to position changes, leading to increased intravascular pressure and dizziness." c. "Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes." d. "While your heart is recovering, blood flow is diverted away from the brain, increasing the risk for stroke when you stand up."

ANS: C Because the new heart is denervated, the baroreceptor and other mechanisms that compensate for blood pressure drops caused by position changes do not function. This allows orthostatic hypotension to persist in the postoperative period. The other options are false statements and do not correctly address the client's question.

16. An older adult patient has a prescription for cyclosporine following a kidney transplant. Which information in the patient's health history has implications for planning patient teaching about the safe use of cyclosporine? a. The patient restricts salt to 2 grams per day. b. The patient eats green leafy vegetables daily. c. The patient drinks grapefruit juice every day. d. The patient drinks 3 to 4 quarts of fluid each day.

ANS: C Grapefruit juice can increase the toxicity of cyclosporine. The patient should be taught to avoid grapefruit juice. Normal fluid and sodium intake or eating green leafy vegetables will not affect cyclosporine levels or renal function.

10. A 53-yr-old patient with stage D heart failure and type 2 diabetes asks the nurse whether heart transplant is an option. Which response is accurate? a. "Your heart failure has not reached the end stage yet." b. "You could not manage the multiple complications of surgery." c. "The suitability of a heart transplant depends on many factors." d. "Because you have diabetes, you would not be a heart transplant candidate."

ANS: C Indications for a heart transplant include end-stage heart failure (stage D), but other factors such as coping skills, family support, and patient motivation to follow the rigorous post-transplant regimen are also considered. Patients with diabetes who have well-controlled blood glucose levels may be candidates for heart transplant. Although heart transplants can be associated with many complications, there are no data to suggest that the patient could not manage the care.

11. A nurse is caring for a client who is about to receive a bone marrow transplant. To best help the client cope with the long recovery period, what action by the nurse is best? a. Arrange a visitation schedule among friends and family. b. Explain that this process is difficult but must be endured. c. Help the client find things to hope for each day of recovery. d. Provide plenty of diversionary activities for this time.

ANS: C Providing hope is an essential nursing function during treatment for any disease process, but especially during the recovery period after bone marrow transplantation, which can take up to 3 weeks. The nurse can help the client look ahead to the recovery period and identify things to hope for during this time. Visitors are important to clients, but may pose an infection risk. Telling the client that the recovery period must be endured does not acknowledge his or her feelings. Diversionary activities are important, but not as important as instilling hope.

19. A nurse reviews the laboratory values of a client who returned from kidney transplantation 12 hours ago: Sodium 136 mEq/L (135 mmol/L) Potassium 5 mEq/L (5 mmol/L) Blood urea nitrogen (BUN) 44 mg/dL (15.7 mmol/L) Serum creatinine 2.5 mg/dL (221 mcmol/L) What initial intervention would the nurse anticipate? a. Start hemodialysis immediately. b. Discuss the need for peritoneal dialysis. c. Increase the dose of immunosuppression. d. Return the client to surgery for exploration.

ANS: C The client may need a higher dose of immunosuppressive medication as evidenced by the elevated BUN and serum creatinine levels. This increased dose may reverse the possible acute rejection of the transplanted kidney. The client does not need hemodialysis, peritoneal dialysis, or further surgery at this point.

25. While waiting for heart transplantation, a patient with severe cardiomyopathy has a ventricular assist device (VAD) implanted. Which action would the nurse include in the plan of care for this patient? a. Preparing the patient for a permanent VAD b. Teaching the patient the reason for bed rest c. Monitoring the incision for signs of infection d. Administering immunosuppressants medications

ANS: C The insertion site for the VAD provides a source for transmission of infection to the circulatory system and requires frequent monitoring. Patients with VADs can have some mobility and may not be on bed rest. The VAD is a bridge to transplantation, not a permanent device. Immunosuppression is not necessary for nonbiologic devices such as the VAD.

17. Which finding is most important for the nurse to communicate to the health care provider about a patient who received a liver transplant 1 week ago? a. Dry palpebral and oral mucosa b. Crackles at bilateral lung bases c. Temperature 100.8F (38.2C) d. No bowel movement for 4 days

ANS: C The risk of infection is high in the first few months after liver transplant, and fever is frequently the only sign of infection. The other patient data indicate the need for further assessment or nursing actions and might be communicated to the health care provider, but they do not indicate a need for

18. The charge nurse is assigning semiprivate rooms for new admissions. Which patient could safely be assigned as a roommate for a patient who has acute rejection of an organ transplant? a. A patient who has viral pneumonia b. A patient with second-degree burns c. A patient with an anaphylactic reaction d. A patient with graft-versus-host disease

ANS: C There is no increased exposure to infection from a patient who had an anaphylactic reaction. Treatment for a patient with acute rejection includes administration of additional immunosuppressants and the patient would not be exposed to increased risk for infection as would occur from patients with viral pneumonia, graft-versus-host disease, and burns.

39. A patient who received a corneal transplant 2 weeks ago calls the ophthalmology clinic to report that his vision has not improved with the transplant. Which action would the nurse take? a. Suggest the patient arrange a ride to the clinic immediately. b. Ask about the presence of "floaters" in the patient's visual field. c. Remind the patient it may take months to restore vision after transplant. d. Teach the patient to continue using prescribed pupil-dilating medications.

ANS: C Vision may not be restored for up to 1 year after corneal transplant. Because the patient is not experiencing complications of the surgery, an emergency clinic visit is not needed. Because "floaters" are not associated with complications of corneal transplant, the nurse will not need to ask the patient about their presence. Corticosteroid drops, not mydriatic drops, are used after corneal transplant surgery.

10. A client has received a bone marrow transplant and is waiting for engraftment. What action(s) by the nurse are most appropriate? (Select all that apply.) a. Not allowing any visitors until engraftment b. Limiting the protein in the client's diet c. Placing the client in protective precautions d. Teaching visitors appropriate hand hygiene e. Telling visitors not to bring live flowers or plants

ANS: C, D, E The client waiting for engraftment after bone marrow transplant has no white cells to protect him or her against infection. The client is on protective precautions and visitors are taught hand hygiene. No fresh flowers or plants are allowed due to the standing water in the vase or container that may harbor organisms; clients are also told not to work with houseplants in the home. Limiting protein is not a healthy option and will not promote engraftment.

12. A client asks about the process of graft-versus-host disease. What explanation by the nurse is correct? a. "Because of immunosuppression, the donor cells take over." b. "It's like a transfusion reaction because no perfect matches exist." c. "The patient's cells are fighting donor cells for dominance." d. "The donor's cells are actually attacking the patient's cells."

ANS: D Graft-versus-host disease is an autoimmune-type process in which the donor cells recognize the client's cells as foreign and begin attacking them. The other answers are not accurate.

26. The nurse completes discharge teaching for a patient who has had a lung transplant. Which patient statement indicates that the teaching has been effective? a. "I will make an appointment to see the doctor every year." b. "I will stop taking the prednisone if I experience a dry cough." c. "I will not worry if I feel a little short of breath with exercise." d. "I will call the health care provider right away if I develop a fever."

ANS: D Low-grade fever may indicate infection or acute rejection, so the patient should notify the health care provider immediately if the temperature is elevated. Patients require frequent follow-up visits with the transplant team. Annual health care provider visits would not be sufficient. Home O2 use is not an expectation after lung transplant. Shortness of breath should be reported. Low-grade fever, fatigue, dyspnea, dry cough, and O2 desaturation are signs of rejection. Immunosuppressive therapy, including prednisone, needs to be continued to prevent rejection.

19. A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, "I know a transplant is my last chance, but I don't want to become a vegetable." How would the nurse respond? a. "Would you like to speak with a priest or chaplain?" b. "I will arrange for a psychiatrist to speak with you." c. "Do you want to come off the transplant list?" d. "Would you like information about advance directives?"

ANS: D The client is verbalizing a real concern or fear about negative outcomes of the surgery. This anxiety itself can have a negative effect on the outcome of the surgery because of sympathetic stimulation. The best action is to allow the client to verbalize the concern and work toward a positive outcome without making the client feel as though the concerns are not valid. The client needs to feel that he or she has some control over the future.

43. A nurse is considering which patient to admit to the same room as a patient who is hospitalized with acute rejection 3 weeks after a liver transplant. Which patient would be the best choice? a. Patient who is receiving chemotherapy for liver cancer b. Patient who is receiving treatment for acute hepatitis C c. Patient who has a wound infection after cholecystectomy d. Patient who requires pain management for chronic pancreatitis

ANS: D The patient with chronic pancreatitis does not present an infection risk to the immunosuppressed patient who had a liver transplant. The other patients either are at risk for infection or currently have an infection, which will place the immunosuppressed patient at risk for infection.