Chapter 13, Altered Immune Responses and Transplantation Study material

The nurse explains about the importance of adherence to immunosuppressive therapy after renal transplant even though the risk of infection is high. What is the best explanation the nurse can give to the patient? Select all that apply. 1) It prevents T-cell activation and proliferation. 2) It inhibits production of T cytotoxic lymphocytes and B cells. 3) It cross-links DNA, leading to cell injury and death. 4) It promotes and facilitates cytokine production of IL-1, IL-6, and TNF. 5) It acts on T helper cells to promote production and release of IL-2 and interferon

Correct 1,2,3, Rationale: Immunosuppressive therapy helps to prevent transplant rejection by suppressing the immune response against the grafted tissue. The mechanism of action may include prevention of T-cell activation and proliferation, inhibition of production of T cytotoxic lymphocytes and B cells, and cross-linking DNA, leading to cell injury and death. Immunosuppressive therapy does not promote cytokine production; instead, it inhibits the production. Immunosuppressive therapy does not act on T cells to help production of interleukin and interferon; instead, it inhibits the production of these mediators.

A patient reports to the nurse experiencing a runny nose, sneezing, and itchy eyes after visiting botanical gardens. Which type of hypersensitivity does the nurse expect to be involved? 1) Type-I 2) Type-II 3) Type-III 4) Type-IV

Correct: 1 Rationale: A botanical garden is full of trees and flowers. Pollen grains in the flowers can precipitate an allergic reaction. Allergic rhinitis is an inflammatory condition of the nasal airways that results when the patient inhales pollen's, dust, and animal dander. Type I hypersensitivity reaction is precipitated by exogenous pollen, dust, food, and drugs such as antigens. Therefore allergic rhinitis involves type I hypersensitivity reaction. Type II hypersensitivity reaction is associated with antibodies directed toward antigens presented on the cell surface of red blood cells and the basement membrane of cells. Presence of extracellular bacteria, viruses, and fungi precipitates type III hypersensitivity. Inter-cellular or extracellular contents precipitate type IV hypersensitivity reaction. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

A nurse is caring for a patient who is admitted for a kidney transplant. A crossmatch prior to the transplant is positive. What should the nurse discuss with the patient and family? 1) Transplantation cannot be done. 2) It is safe to proceed with the transplantation. 3) A renal scan needs to be done to confirm transplantation. 4) If transplanted, the organ would undergo a hyperacute rejection. 5) It is safe to proceed with the transplantation for now, but chronic rejection is anticipated.

Correct: 1 & 4

During administration of chemotherapy to a patient with breast cancer, the patient develops urticaria and shortness of breath. What is the priority action by the nurse after stopping therapy? Select all that apply. 1) Ensure airway patency. 2) Check the patient's temperature. 3) Take the patient's blood pressure. 4) Obtain the patient's pulse oximetry. 5) Assess the patient's respiratory status.

Correct: 1, 4, 5 Rationale: The patient is experiencing an allergic reaction, which may lead to anaphylaxis. Anaphylactic shock can lead to respiratory distress as a result of laryngeal edema or severe bronchospasm. Pulse oximetry should be obtained to determine oxygen saturation after airway patency is ensured and maintained. Respiratory status should be checked to determine respiratory distress. Assessing and maintaining the patient's airway is the priority. Measuring temperature and blood pressure is not the priority and can be done later after the patient is stabilized.

A nurse gives information about administration of immunotherapy to a patient. What should the nurse include in the instruction? Select all that apply. 1) Warn the patient about a delayed reaction. 2) Anticipate an adverse reaction after a missed dose. 3) Keep emergency equipment ready during administration. 4) Always administer allergen extract in an extremity close to the joint. 5) An injection should be given directly into the blood stream for immediate action.

Correct: 1,2,3

Following a patch test, the patient experiences severe pruritus and erythema around the patch area. What are the most appropriate immediate nursing interventions? Select all that apply. 1) Remove the test patch from the area. 2) Apply topical anti inflammatory cream. 3) Report the reaction to the health care provider. 4) Administer a subcutaneous injection of epinephrine. 5) Document the reaction in the patient's medical records.

Correct: 1,2,4 Rationale: Following a patch test, if the patient experiences severe pruritus and erythema around the patch area, it indicates anaphylactic reaction. To prevent it from becoming severe, the nurse should immediately remove the patch and apply antiinflammatory cream topically. A subcutaneous injection of epinephrine can also be given to decrease the severity of the reaction. Documenting and reporting are completed only once the patient is stable.

A nurse is administering subcutaneous immunotherapy to a patient who is sensitive to insect stings. Which statement would the nurse include in patient education regarding immunotherapy? Select all that apply. 1) This therapy will be continued for at least 5 years, but may be indefinite. 2) The dose is small at first and then increased slowly. 3) This therapy should be administered once every year. 4) In this therapy, subcutaneous injections of allergens are given. 5) Maintenance therapy is continued indefinitely only for patients with minor allergies and no sensitivity to insect stings.

Correct: 1,2,4 Rationale: Immunotherapy aims to control allergic symptoms when it is not possible to avoid the allergen and when drug therapy is not effective. The therapy involves the subcutaneous injection of the allergen in small doses, which are gradually increased. The amount of dose is gradually increased till the maintenance dosage is reached. After continuing the therapy for 5 years, discontinuation is considered, but not guaranteed. The titrated amounts of allergen extracts are given weekly or biweekly, not once a year. Generally, a decrease in symptoms is observed after the procedure is discontinued. Sometimes, maintenance therapy needs to be continued indefinitely if the patient is sensitive to insect stings or has severe allergies.

Which interventions by the nurse optimize safety and comfort during administration of an allergen extract to a patient? Select all that apply. 1) Rotating the site for each injection 2) Aspirating for blood before giving an injection 3) Injecting the allergen directly into the bloodstream 4) Administering the drug extract close to an arm or leg joint 5) Monitoring the patient for 20 minutes after giving the injection

Correct: 1,2,5 Rationale: Administration of allergen extract to a patient requires careful planning and implementation. The site should be rotated after each injection to promote absorption. Blood should be aspirated before giving an injection to ensure that the allergen is not injected into the blood vessel. The patient should be monitored for 20 minutes after giving the injection because systemic reactions are most likely to occur during this period. The allergen should not be injected directly into the bloodstream because it may potentiate an anaphylactic reaction. The drug extract sh

During a follow-up visit with a patient who is recovering from a kidney transplant, which organ systems should the nurse assess to determine graft-versus-host disease (GVHD)? Select all that apply. 1) Skin 2) Liver 3) Ears 4) Chest 5) Gastrointestinal (GI) tract

Correct: 1,2,5 Rationale: The nurse should assess the skin, liver, and GI tract for determining GVHD after kidney transplantation. The skin manifestations include a pruritic or painful maculopapular rash, which usually starts on the palms and soles of the feet and gradually spreads to a generalized erythema. Bullous formation and desquamation may also be seen. The liver disease caused by GVHD may range from mild jaundice with elevated liver enzymes to hepatic coma. The GI symptoms may include mild to severe diarrhea, severe abdominal pain, GI bleeding, and malabsorption. The ears and chest are checked as part of routine care, but not specifically when assessing for GVHD. STUDY TIP: A helpful method for decreasing test stress is to practice self-affirmation. After you have adequately studied and really know the material, start looking in the mirror each time you pass one and say to yourself—preferably out loud—"I know this material, and I will do well on the test." After several times of watching and hearing yourself reaffirm your knowledge, you will gain inner confidence and be able to perform much better during the test period. This technique really works for students who are adventurous enough to use it. It may feel silly at first, but if it works, who cares? It will work for performing skills in clinical as well, as long as you have practiced the skill sufficiently.

A nurse is preparing to administer lymphocyte immune globulin. Which measures should the nurse take to prevent the side effects when administering lymphocyte immune globulin? Select all that apply. 1) Administer the drug over 4 to 6 hours. 2) Discontinue the use of drug if side effects appear. 3) Educate the patient about infection prevention measures. 4) Closely monitor the patient for an increase in severity of side effects. 5) Premedicate with acetaminophen, diphenhydramine, and methylprednisolone.

Correct: 1,4,5 Rationale: To reduce the side effects of lymphocyte immune globulin (Atgam) the nurse should administer the drug slowly over 4 to 6 hours and premedicate the patient with acetaminophen, diphenhydramine, and methylprednisolone. In addition, the patient should be closely monitored for adverse effects. Fever, arthralgias, and tachycardia are the common side effects caused by an allergic reaction to the foreign protein of the host animal. However, the side effects are not too severe to discontinue the use of the drug. The patient should be educated about prevention of infection as a general measure; however, prevention does not contribute to decreasing the symptoms.

The nurse is performing an assessment for a patient who reports problems with seasonal allergy. What questions would be appropriate for the nurse to ask to gather the most important data? Select all that apply. 1) "Do you have a pet?" 2) "Do you have diabetes?" 3) "Do you exercise regularly?" 4) "When did your last menstrual cycle end?" 5) "Have you used any over-the-counter drugs?"

Correct: 1,5 Rationale: Taking over-the-counter medicines can be a contributing factor allergy. Information should be obtained about which over-the-counter medications have been taken by the patient. Often, the hair of pets can cause allergies. Many people are allergic to pets and pet dander. Therefore it is important to ask the patient about any pets at home. A detection of the patient's family history of diabetes will not contribute in assessing allergy symptoms. The last date of the patient's menstruation period will not help in the assessment of allergies. Also, exercising regularly is not related to allergies.

A patient is given acetaminophen, diphenhydramine, and IV methylprednisolone before administering a dose of muromonab-CD3. What explanation will the nurse give for the reason for these medications? Select all that apply. 1) To prevent rigors 2) To increase the production of T-cells 3) To provide protection against infection 4) To hasten the action of muromonab-CD3 5) To prevent various gastrointestinal (GI) disturbances

Correct: 1,5, Rationale: Administration of muromonab-CD3 is associated with side effects such as GI disturbances, fever, rigors, and headache. Administration of these medicines prior to muromonab-CD3 therapy helps to reduce side effects. The medicine does not hasten the action of muromonab-CD 3; neither does it protect against any infection or increase the protection of T-cells.

A patient underwent a kidney transplant. What tests will the nurse prepare the patient for that will determine renal insufficiency? Select all that apply. 1) Renal ultrasound 2) Blood urea nitrogen 3) Serum creatinine level 4) 24-hour urinary output 5) White blood cell (WBC) count

Correct: 2,3

A patient is admitted to the hospital with allergic rhinitis. Which medications should be included in the treatment plan of the patient? Select all that apply. 1) Use of antipruritics 2) Use of antihistamines 3) Use of epinephrine 4) Use of mast cell stabilizers 5) Use of oral corticosteroids

Correct: 2,4,5 Rationale: Antihistamines are the best drugs to treat allergic rhinitis. They act by competing with histamine for H1-receptor sites and thus block the effect of histamine. Mast cell-stabilizing drugs inhibit the release of histamines and are used in management of allergic rhinitis. If there is severe manifestation of allergic rhinitis, a brief course of oral corticosteroids is indicated. Antipruritic drugs are used for insect bites to protect the skin and provide relief from itching. The major sympathomimetic, epinephrine, is used in anaphylactic reaction. Minor sympathomimetic drugs are used to treat allergic rhinitis.

A patient with severe anaphylactic reaction is experiencing hypovolemic shock. What physiologic change will help the patient to compensate for the hemodynamic imbalance? 1) Activation of neurons 2) Stimulation of protein kinase 3) Constriction of peripheral blood vessels 4) Suppression of the sympathetic nervous system

Correct: 3 Rationale: Hypovolemic shock during an anaphylactic reaction is associated with loss of fluid in the interstitial space due to massive vasodilation. Peripheral vasoconstriction, or constriction of peripheral blood vessels, will help the patient's body compensate for the fluid shift by increasing the heart rate. Activation of neurons helps transfer signals and impulses, but does not compensate for hypovolemic shock. Stimulation of protein kinase will result in vasodilation, which may increase the intensity of hypovolemic shock. Activation, rather than suppression, of the sympathetic nervous system will constrict arterial resistance vessel and help to compensate for hypovolemic shock.

The nurse is caring for a patient scheduled for a kidney transplant. What education should the nurse provide the patient in preparation for the transplant? Select all that apply. 1) Avoid all exercise, work, and sports activities. 2) Production of urine will be delayed after surgery. 3) Immunosuppressive drugs daily will be required. 4) Transplantation will be performed only if crossmatching is negative. 5) Symptoms of rejection include a decrease in temperature and blood pressure

Correct: 3,4 Rationale: Immunosuppressive agents are administered to reduce the immune system's tendency to reject the transplanted organ. A crossmatch uses serum from the recipient mixed with donor lymphocytes to test for any preformed anti-HLA antibodies to the potential donor organ. A negative crossmatch indicates that no preformed antibodies are present, and it is safe to proceed with transplantation. Urine production occurs almost immediately. If the transplant is rejected, the patient may experience a rise in temperature and blood pressure due to fluid retention. Although recreation and exercise are encouraged, strenuous sports activities should be strictly avoided.