Lewis Med-Surg Ch. 13 Altered Immune Responses and Transplantation
A patient waiting for a kidney transplant asks the nurse to explain the difference between a negative and positive crossmatch. Which statement by the nurse would be the most accurate response? "A negative crossmatch means that both the donor and recipient are Rh negative, and the transplant is safe." "A negative crossmatch means that no preformed antibodies are present and the transplant would be safe." "A positive crossmatch means the blood type is the same between donor and recipient, and the transplant is safe." "A positive crossmatch means that both the donor and the recipient have antigens that are similar, and the transplant would be safe."
"A negative crossmatch means that no preformed antibodies are present and the transplant would be safe." A crossmatch uses serum from the recipient mixed with donor lymphocytes to test for any preformed antibodies to the potential donor organ. A positive crossmatch indicates that the recipient has cytotoxic antibodies to the donor and is an absolute contraindication to transplantation.
The nurse is teaching a patient with a latex allergy about preventing and treating allergic reactions. Which statement, if made by the patient, indicates a need for further teaching? "My dentist should be told about my latex allergy." "I should avoid foods such as bananas, avocados, and kiwi." "I will use vinyl gloves for activities such as housekeeping." "Because my reactions are not severe, I will not need an EpiPen."
"Because my reactions are not severe, I will not need an EpiPen."
Which statement by the patient who has had an organ transplant would indicate that the patient understands the teaching about the immunosuppressive medications? "My drug dosages will be lower because the medications enhance each other." "Taking more than one medication will put me at risk for developing allergies." "I will be more prone to malignancies because I will be taking more than one drug." "The lower doses of my medications can prevent rejection and minimize the side effects."
"The lower doses of my medications can prevent rejection and minimize the side effects." 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.
Which statement made by the nurse is most appropriate in teaching patient interventions to minimize the effects of seasonal allergic rhinitis? "You will need to get rid of your pets." "You should sleep in an air-conditioned room." "You would do best to stay indoors during the winter months." "You will need to dust your house with a dry feather duster twice a week."
"You should sleep in an air-conditioned room." Seasonal allergic rhinitis is most commonly 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.
Which patient is at risk for developing graft-versus-host disease (GVHD)? A 65-yr-old man who received an autologous blood transfusion A 40-yr-old man who received a kidney transplant from a living donor A 65-yr-old woman who received a pancreas and kidney from a deceased donor A 40-yr-old woman who received a bone marrow transplant from a close relative
A 40-yr-old woman who received a bone marrow transplant from a close relative *GVHD* occurs when an *immunoincompetent patient* is transfused or *transplanted with immunocompetent cells*. Examples include *blood transfusions* or the *transplantation of bone marrow*, fetal thymus, or fetal liver. An autologous blood transfusion is the collection and reinfusion of the individual's own blood or blood components. There is no risk for GVHD in this situation.
When caring for a patient with a known latex allergy, the nurse would monitor the patient closely for a cross-sensitivity to which foods (select all that apply.)? Select all that apply. a. Grapes b. Oranges c. Bananas d. Potatoes e. Tomatoes
A, C, D, E a. Grapes c. Bananas d. Potatoes e. Tomatoes
A patient who is receiving an IV antibiotic develops wheezes and dyspnea. In which order should the nurse implement these prescribed actions? (Put a comma and a space between each answer choice [A, B, C, D, E]). a. Discontinue the antibiotic. b. Give diphenhydramine IV. c. Inject epinephrine IM or IV. d. Prepare an infusion of dopamine. e. Provide 100% oxygen using a nonrebreather mask.
A, E, C, B, D a. Discontinue the antibiotic. e. Provide 100% oxygen using a nonrebreather mask. c. Inject epinephrine IM or IV. b. Give diphenhydramine IV d. Prepare an infusion of dopamine.
Ten days after receiving a bone marrow transplant, a patient develops a skin rash on the palms and soles, jaundice, and diarrhea. What does the nurse determine these clinical manifestations are indicating? The patient is experiencing a type I allergic reaction. An atopic reaction is causing the patient's symptoms. The patient is experiencing rejection of the bone marrow. Cells in the transplanted bone marrow are attacking the host tissue.
Cells in the transplanted bone marrow are attacking the host tissue.
The nurse is assessing an older adult patient. What type of age related disorders should the nurse assess for related to the increased immunologic response? Autoimmune response Cell-mediated immunity Hypersensitivity response Humoral immune response
Autoimmune response With aging, autoantibodies increase, which lead to autoimmune diseases (e.g., systemic lupus erythematosus, acute glomerulonephritis, rheumatoid arthritis, hypothyroidism). Cell-mediated immunity decreases with decreased thymic output of T cells and decreased activation of both T and B cells.
A patient with systemic *lupus erythematosus* is receiving *plasmapheresis* to treat an acute attack. What symptoms will the nurse monitor to determine if the patient develops *complications* related to the procedure? Hypotension, paresthesias, and dizziness Polyuria, decreased reflexes, and lethargy Intense thirst, flushed skin, and weight gain Abdominal cramping, diarrhea, and leg weakness
Hypotension, paresthesias, and dizziness Common complications associated with *plasmapheresis* are *hypotension and citrate toxicity*. *Citrate* is used as an anticoagulant and may cause *hypocalcemia*, which may manifest as *headache, paresthesias, and dizziness*.
The patient with an autoimmune disease will be treated with plasmapheresis. What should the nurse teach the patient about this treatment? It will gather platelets for use later when needed. It will cause anemia because it removes whole blood and red blood cells are damaged. It will remove the IgG autoantibodies and antigen complexes from the plasma. It will remove the peripheral stem cells in order to cure the autoimmune disease.
It will remove the IgG autoantibodies and antigen complexes from the plasma. Plasmapheresis removes plasma that contains autoantibodies (usually IgG class) and antigen-antibody complexes to remove the pathologic substances in the plasma without causing anemia.
A patient received penicillin V *potassium intramuscular (IM)* causing a systemic *anaphylactic reaction*. What manifestations does the nurse observe initially? Dyspnea Dilated pupils Itching and edema Wheal-and-flare reaction
Itching and edema A systemic anaphylactic reaction starts with edema and itching at the site of exposure to the antigen. Shock can rapidly develop with rapid, weak pulse; hypotension; dilated pupils; dyspnea; and possible cyanosis.
A patient has begun immunotherapy for the treatment of intractable environmental allergies. When administering the patient's immunotherapy, what is the nurse's priority action? Monitor the patient's fluid balance. Assess the patient's need for analgesia. Monitor for signs and symptoms of an adverse reaction. Assess the patient for changes in level of consciousness.
Monitor for signs and symptoms of an adverse reaction. When administering immunotherapy, it is imperative to closely monitor the patient for any signs of an adverse reaction.
The patient with an allergy to bee stings was just stung by a bee. After administering oxygen, removing the stinger, and administering epinephrine, the nurse notices the patient is hypotensive. What should be the nurse's first action? Administer IV diphenhydramine. Administer nitroprusside as soon as possible. Anticipate tracheostomy with laryngeal edema. Place the patient recumbent and elevate the legs.
Place the patient recumbent and elevate the legs. In this emergency situation, the ABCs (airway, breathing, circulation) are being followed. For *hypotension*, the patient should be placed in a *recumbent position* with the *legs elevated*, epinephrine will continue to be administered every 2 to 5 minutes, and fluids will be administered with vasopressors. *Diphenhydramine* is an *antihistamine* used to treat *allergy symptoms*. Anticipating a tracheostomy may occur with ongoing patient monitoring. Nitroprusside is a vasodilator and would not be used now.
A patient being tested for multiple allergies develops localized redness and swelling in reaction to a patch skin test. Which intervention by the nurse would have the highest priority? Notify the health care provider. Administer oral diphenhydramine. Apply a topical antiinflammatory cream. Remove the patch and extract from the skin.
Remove the patch and extract from the skin If a severe reaction to a patch skin test occurs, the nurse should immediately remove the patch and the extract from the skin.
The patient with diabetes mellitus has been chronically ill with a severe lung infection needing corticosteroids and antibiotics. What condition should the nurse monitor for related to the patient's condition? Major histoincompatibility Primary immunodeficiency Secondary immunodeficiency Acute hypersensitivity reaction
Secondary immunodeficiency Secondary immunodeficiency is most commonly caused by immunosuppressive drugs, such as corticosteroids. It can also be caused by diabetes mellitus, severe infection, malnutrition, and chronic stress, all of which are present in this patient.
A patient has a hemoglobin level of 8.2 gm/dL and hematocrit of 28%, and is receiving a transfusion of packed red blood cells. The patient reports back pain, chills, and has a fever during the transfusion. What is the priority nursing action? Call the physician Stop the transfusion Administer acetaminophen for the pain and fever Monitor the patient for the remainder of the transfusion
Stop the transfusion
A healthy older adult patient requests a "flu shot" during an office visit. When assessing the patient, what other vaccinations should the nurse ask the patient about receiving (select all that apply.)? Select all that apply. a. Shingles b. Pneumonia c. Meningococcal d. Haemophilus influenzae type b (Hib) e. Measles, mumps, and rubella (MMR)
a, b, a. Shingles b. Pneumonia The patient should receive the vaccines for shingles (herpes zoster), pneumococcus, and influenza.
An older adult patient who is having an annual check-up tells the nurse, "I feel fine, and I don't want to pay for all these unnecessary cancer screening tests!" Which information should the nurse plan to teach this patient? a. Consequences of aging on cell-mediated immunity b. Decrease in antibody production associated with aging c. Impact of poor nutrition on immune function in older people d. Incidence of cancer-associated infections in older individuals
a. Consequences of aging on cell-mediated immunity The primary impact of aging on immune function is on T cells, which are important for immune surveillance and tumor immunity.
A patient is being evaluated for possible atopic dermatitis. The nurse expects elevation of which laboratory value? a. IgE c. Basophils b. IgA d. Neutrophils
a. IgE Serum IgE is elevated in an allergic response (type 1 hypersensitivity disorders).
Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What would the nurse suspect is the cause of the rash? a. The donor T cells are attacking the patient's skin cells. b. The patient needs treatment to prevent hyperacute rejection. c. The patient's antibodies are rejecting the donor bone marrow. d. The patient is experiencing a delayed hypersensitivity reaction.
a. The donor T cells are attacking the patient's skin cells. 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.
The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions? a. "I need to be monitored closely for development of malignant tumors." b. "After a couple of years I will be able to stop taking the cyclosporine." c. "If I develop acute rejection episode, I will need additional types of drugs." d. "The drugs are combined to inhibit different ways the kidney can be rejected."
b. "After a couple of years I will be able to stop taking the cyclosporine." Cyclosporine, a calcineurin inhibitor, will need to be continued for life.
Which statement by a patient would alert the nurse to a risk for decreased immune function? a. "I had a chest x-ray 6 months ago." b. "I had my spleen removed after a car accident." c. "I take one baby aspirin every day to prevent stroke." d. "I usually eat eggs or meat for at least two meals a day."
b. "I had my spleen removed after a car accident."
A patient who collects honey to earn supplemental income has developed a hypersensitivity to bee stings. Which statement, if made by the patient, would indicate a need for additional teaching? a. "I need to find a different way to earn extra money." b. "I will take oral antihistamines before going to work." c. "I will get a prescription for epinephrine and learn to self-inject it." d. "I should wear a Medic-Alert bracelet indicating my allergy to bee stings."
b. "I will take oral antihistamines before going to work."
A patient in the health care provider's office for allergen testing using the cutaneous scratch method develops itching and swelling at the skin site. Which action should the nurse take first? a. Monitor the patient's edema. b. Administer a dose of epinephrine. c. Provide a prescription for oral antihistamines d. Ask the patient about the use of new skin products.
b. Administer a dose of epinephrine
Immediately after the nurse administers an intracutaneous injection of an allergen on the forearm, the patient complains of itching at the site, weakness, and dizziness. What action should the nurse take first? a. Apply antiinflammatory cream. b. Place a tourniquet above the site. c. Administer subcutaneous epinephrine. d. Reschedule the patient's other allergen tests.
b. Place a tourniquet above the site.
A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse prepare 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
b. Administration of immunosuppressant medications Acute rejection is treated with the administration of additional immunosuppressant drugs such as corticosteroids. Because acute rejection is potentially reversible, there is no indication that the patient will require another transplant or hemodialysis.
Which example should the nurse use to explain an infant's "passive immunity" to a new mother? a. Vaccinations b. Breastfeeding c. Stem cells in peripheral blood d. Exposure to communicable diseases
b. Breastfeeding Colostrum in breast milk provides passive immunity through antibodies from the mother.
The nurse taking a health history learns that the patient, who has worked in rubber tire manufacturing, has allergic rhinitis and multiple food allergies. Which action by the nurse is correct? a. Recommend that the patient use latex gloves in preventing blood-borne pathogen contact. b. Document the patient's history and teach about clinical manifestations of a type I latex allergy. c. Encourage the patient to carry an epinephrine kit in case a type IV allergic reaction to latex develops. d. Advise the patient to use oil-based hand creams to decrease contact with natural proteins in latex gloves.
b. Document the patient's history and teach about clinical manifestations of a type I latex allergy.
A patient seeks care in the emergency department after sharing needles for heroin injection with a friend who has hepatitis B. To provide immediate protection from infection, what medication will the nurse expect to administer? a. Corticosteroids c. Hepatitis B vaccine b. Gamma globulin d. Fresh frozen plasma
b. Gamma globulin The patient should first receive antibodies for hepatitis B from injection of gamma globulin. The hepatitis B vaccination series should be started to provide active immunity.
Which patient should the nurse assess first? a. Patient with urticaria after receiving an IV antibiotic b. Patient who is sneezing after subcutaneous immunotherapy c. Patient who has graft-versus-host disease and severe diarrhea d. Patient with multiple chemical sensitivities who has muscle stiffness
b. Patient who is sneezing after subcutaneous immunotherapy Sneezing after subcutaneous immunotherapy may indicate impending anaphylaxis and assessment and emergency measures should be initiated.
The nurse provides discharge instructions to a patient who has an immune deficiency involving the T lymphocytes. Which health screening should the nurse include in the teaching plan for this patient? a. Screening for allergies b. Screening for malignancies c. Screening for antibody deficiencies d. Screening for autoimmune disorders
b. Screening for malignancies Cell-mediated immunity is responsible for the recognition and destruction of cancer cells.
Which information about intradermal skin testing should the nurse teach to a patient with possible allergies? a. "Do not eat anything for about 6 hours before the testing." b. "Take an oral antihistamine about an hour before the testing." c. "Plan to wait in the clinic for 20 to 30 minutes after the testing." d. "Reaction to the testing will take about 48 to 72 hours to occur."
c. "Plan to wait in the clinic for 20 to 30 minutes after the testing." Allergic reactions usually occur within minutes after injection of an allergen, and the patient will be monitored for at least 20 minutes for anaphylactic reactions after the testing.
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 who is recovering from an anaphylactic reaction to a bee sting d. A patient with graft-versus-host disease after a recent bone marrow transplant
c. A patient who is recovering from an anaphylactic reaction to a bee sting There is no increased exposure to infection from a patient who had an anaphylactic reaction.
A patient is anxious and reports difficulty breathing after being stung by a wasp. What is the nurse's priority action? a. Provide high-flow oxygen. c. Assess the patient's airway. b. Administer antihistamines. d. Remove the stinger from the site.
c. Assess the patient's airway.
The nurse reviewing a clinic patient's medical record notes that the patient missed the previous appointment for weekly immunotherapy. Which action by the nurse is appropriate? a. Schedule an additional dose the following week. b. Administer the scheduled dosage of the allergen. c. Consult with the health care provider about giving a lower allergen dose. d. Re-evaluate the patient's sensitivity to the allergen with a repeat skin test.
c. Consult with the health care provider about giving a lower allergen dose. Because there is an increased risk for adverse reactions after a patient misses a scheduled dose of allergen, the nurse should check with the health care provider before administration of the injection.
The health care provider asks the nurse whether a patient's angioedema has responded to prescribed therapies. Which assessment should the nurse perform? a. Obtain the patient's blood pressure and heart rate. b. Question the patient about any clear nasal discharge. c. Observe for swelling of the patient's lips and tongue. d. Assess the patient's extremities for wheal and flare lesions.
c. Observe for swelling of the patient's lips and tongue.
What instructions about plasmapheresis should the nurse include in the teaching plan for a patient diagnosed with systemic lupus erythematosus (SLE)? a. Plasmapheresis eliminates eosinophils and basophils from blood. b. Plasmapheresis decreases the damage to organs from T lymphocytes. c. Plasmapheresis removes antibody-antigen complexes from circulation. d. Plasmapheresis prevents foreign antibodies from damaging various body tissues.
c. Plasmapheresis removes antibody-antigen complexes from circulation. Plasmapheresis is used in SLE to remove antibodies, antibody-antigen complexes, and complement from blood. T lymphocytes, foreign antibodies, eosinophils, and basophils do not directly contribute to the tissue damage in SLE.
A nurse has obtained donor tissue typing information about a patient who is waiting for a kidney transplant. Which results should be reported to the transplant surgeon? a. Patient is Rh positive and donor is Rh negative b. Six antigen matches are present in HLA typing c. Results of patient-donor crossmatching are positive d. Panel of reactive antibodies (PRA) percentage is low
c. Results of patient-donor crossmatching are positive Positive crossmatching is an absolute contraindication to kidney transplantation because a hyperacute rejection will occur after the transplant.
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 medication at this time? 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.
c. The patient drinks grapefruit juice every day. Grapefruit juice can increase the toxicity of cyclosporine.
A clinic patient is experiencing an allergic reaction to an unknown allergen. Which action is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Perform a focused physical assessment. b. Obtain the health history from the patient. c. Teach the patient about the various diagnostic studies. d. Administer a skin test by the cutaneous scratch method.
d. Administer a skin test by the cutaneous scratch method. LPN/LVNs are educated and licensed to administer medications under the supervision of an RN.
The nurse should assess the patient undergoing plasmapheresis for which clinical manifestation? a. Shortness of breath c. Transfusion reaction b. High blood pressure d. Extremity numbness
d. Extremity numbness Numbness and tingling may occur as the result of the hypocalcemia caused by the citrate used to prevent coagulation.
A patient who is receiving immunotherapy has just received an allergen injection. Which assessment finding is most important to communicate to the health care provider? a. The patient's IgG level is increased. b. The injection site is red and swollen. c. The patient's symptoms did not improve in 2 months. d. There is a 2-cm wheal at the site of the allergen injection.
d. There is a 2-cm wheal at the site of the allergen injection. A local reaction larger than quarter size may indicate that a decrease in the allergen dose is needed.