Chapter 14: Immune Responses and Transplantation Harding: Lewis’s Medical-Surgical Nursing,

1. Which health promotion action would the nurse include in the teaching plan for a patient who

has an immune deficiency involving the T lymphocytes?

a. Screening for cancers

b. Screening for allergies

c. Screening for antibody deficiencies

d. Screening for autoimmune disorders

ANS: A. Screening for cancers

Cell-mediated immunity is responsible for the recognition and destruction of cancer cells.

Allergic reactions, autoimmune disorders, and antibody deficiencies are mediated primarily

by B lymphocytes and humoral immunity.

2. Which example would 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

ANS: B. Breastfeeding

Colostrum in breast milk provides passive immunity through antibodies from the mother.

These antibodies protect the infant for a few months. However, memory cells are not retained,

so the protection is not permanent. Active immunity is acquired by being immunized with

vaccinations or having an infection. Stem cells are unspecialized cells used to repopulate a

person‗s bone marrow after high-dose chemotherapy.

3. Which laboratory value would the nurse expect to be elevated in a patient who has atopic dermatitis?

a. IgA

b. IgE

c. Basophils

d. Neutrophils

ANS: B. IgE

Serum IgE is elevated in an allergic response (type 1 hypersensitivity disorders). The

eosinophil level will be elevated rather than neutrophil or basophil counts. IgA is in body

secretions and would not be tested when evaluating a patient who has symptoms of atopic

dermatitis.

4. A healthy older adult patient who is having an annual checkup tells the nurse, ―I feel fine, and I don‗t want to pay for unnecessary cancer screening tests.‖ Which information would the

nurse plan to teach this patient?

a. Consequences of aging on cell-mediated immunity

b. Decrease in antibody production associated with aging

c. Incidence of cancer-associated infections in older adults

d. Impact of poor nutrition on immune function in older adults

ANS: 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. Antibody function is not affected as much by

aging. Poor nutrition can also contribute to decreased immunity, but there is no evidence that

it is a contributing factor for this patient. Although some types of cancer are associated with

specific infections, this patient does not have evidence of an active infection.

5. A patient who works with bees and collects honey has developed a hypersensitivity to bee stings. Which statement by the patient would indicate a need for additional teaching?

a. ―I should consider alternative employment options.‖

b. ―I will take oral antihistamines before going to work.‖

c. ―I can get a prescription for epinephrine and learn to self-inject it.‖

d. ―I need to always wear a Medic-Alert bracelet indicating my allergy.‖

ANS: B. will take oral antihistamines before going to work.‖

Because the patient is at risk for bee stings and the severity of allergic reactions tends to

increase with added exposure to allergen, taking oral antihistamines will not adequately

control the patient‗s hypersensitivity reaction. The other patient statements indicate a good

understanding of management of the problem.

6. Which information about intradermal skin testing would 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 about 20 minutes after the testing.‖

d. ―Reaction to the testing will take about 72 hours to occur.‖

ANS: C. Plan to wait in the clinic for about 20 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.

Medications that might modify the response, such as antihistamines, would be avoided before

allergy testing. There is no reason to be NPO for skin testing. Results with intradermal testing

occur within minutes.

7. The nurse reviewing a clinic patient‗s medical record notes that the patient missed the previous appointment for weekly immunotherapy. Which action would the nurse take?

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. Reevaluate the patient‗s sensitivity to the allergen with a repeat skin test.

ANS: 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 would check with the health care provider before administration of the

injection. A skin test is used to identify the allergen and would not be used at this time. An

additional dose for the week may increase the risk for a reaction.

8. 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 would the nurse take?

a. Recommend that the patient use latex gloves in preventing blood-borne pathogen contact.

b. Document the patients 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. Tell the patient to use oil-based hand creams to decrease contact with natural proteins in latex gloves.

ANS: B. Document the patients history and teach about clinical manifestations of a type I latex allergy.

The patient‗s allergy history and occupation indicate a risk of developing a latex allergy.

Teach the patient about symptoms that may occur. Epinephrine is not an appropriate treatment

for contact dermatitis that is caused by a type IV allergic reaction to latex. Using latex gloves

increases the chance of developing latex sensitivity. Oil-based creams will increase the

exposure to latex from latex gloves.

9. Which information about plasmapheresis would the nurse include in the teaching plan for a patient diagnosed with systemic lupus erythematosus (SLE)?

a. Plasmapheresis counteracts recovery of IgG production.

b. Plasmapheresis removes eosinophils and basophils from the blood.

c. Plasmapheresis decreases the damage to organs from T lymphocytes.

d. Plasmapheresis prevents inflammatory mediators from injuring tissues.

ANS: D. Plasmapheresis prevents inflammatory mediators from injuring tissues.

Plasmapheresis is used in SLE to remove antibodies, antibody-antigen complexes, and inflammatory mediators, such as complement, from the blood. T lymphocytes, foreign

antibodies, eosinophils, and basophils do not directly contribute to the tissue damage in SLE.

Immunosuppressive therapy is used to prevent recovery of IgG production.

10. The nurse would assess the patient undergoing plasmapheresis for which clinical manifestation?

a. Shortness of breath

b. High blood pressure

c. Transfusion reaction

d. Extremity numbness

ANS: D. Extremity numbness

Numbness and tingling may occur as the result of the hypocalcemia caused by the citrate used

to prevent coagulation. The other clinical manifestations are not associated with

plasmapheresis.

11. Which patient statement 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.‖

ANS: B. I had my spleen removed after a car accident.‖

Splenectomy increases the risk for septicemia from bacterial infections. The patient‗s protein

intake is good and should support immune function. Daily aspirin use does not affect immune

function. A chest x-ray does not have enough radiation to suppress immune function.

12. Which patient would the nurse assess first?

a. Patient with hives 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 with muscle stiffness

ANS: 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 other patients also have findings

that need assessment and intervention by the nurse, but do not have evidence of

life-threatening complications.

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 cells are being attacked by the donor T cell.

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 history and symptoms

are not consistent with rejection or delayed hypersensitivity.

14. 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

b. Gamma globulin

c. Hepatitis B vaccine

d. Fresh frozen plasma

ANS: B. Gamma globulin

The patient would first receive antibodies for hepatitis B from injection of gamma globulin.

The hepatitis B vaccination series would be started to provide active immunity. Fresh frozen

plasma and corticosteroids will not be effective in preventing hepatitis B in the patient.

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. After a couple of years, I will be able to stop taking immunosuppressants.‖

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.

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. The patient drinks grapefruit juice every day.

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.

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. 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 sign that the

patient will need another transplant or hemodialysis. There is no need to repeat HLA testing.

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. A patient with an anaphylactic reaction

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.

19. 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 would the nurse plan to take first?

a. Monitor the patients edema.

b. Administer a dose of epinephrine.

c. Obtain a prescription for oral antihistamines.

d. Assess the patients use of new skin products.

ANS: B. Administer a dose of epinephrine.

Rapid administration of epinephrine when excessive itching or swelling at the skin site is

observed can prevent the progression to anaphylaxis. The initial symptoms of anaphylaxis are

itching and edema at the site of the exposure. The nurse should not wait and assess for

development of more edema. Hypotension, tachycardia, dilated pupils, and wheezes occur

later. Exposure to skin products does not address the immediate concern of a possible

anaphylactic reaction.

20. A patient in the emergency room is anxious and reports difficulty breathing after being stung by a wasp. Which action would the nurse take first?

a. Provide high-flow oxygen.

b. Administer antihistamines.

c. Assess the patients airway.

d. Remove the stinger from the site.

ANS: C. Assess the patients airway.

The initial action with any patient with difficulty breathing is to assess and maintain the

airway. The patient‗s symptoms of anxiety and difficulty breathing may have other causes

than anaphylaxis, so additional assessment is warranted. The other actions are part of the

emergency management protocol for anaphylaxis, but the priority is airway assessment and

maintenance.

21. Immediately after the nurse administers an intradermal injection of an allergen on the forearm, the patient reports itching at the site, weakness, and dizziness. Which action would 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.

ANS: B. Place a tourniquet above the site.

Application of a tourniquet will decrease systemic circulation of the allergen and should be

the first reaction. The other actions may occur, but the tourniquet application slows the

allergen progress into the patient‗s system, allowing treatment of the anaphylactic response. A

local antiinflammatory cream may be applied to the site of a cutaneous test for persistent

itching. Epinephrine will be needed if the allergic reaction progresses to anaphylaxis. Other

testing may be delayed and rescheduled after development of anaphylaxis.

22. A clinic patient reports experiencing an allergic reaction to an unknown allergen several weeks ago. Which action is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/VN)?

a. Perform a focused physical assessment.

b. Administer a cutaneous scratch skin test.

c. Obtain the health history from the patient.

d. Review diagnostic study results with the patient.

ANS: B. Administer a cutaneous scratch skin test.

LPN/VNs are educated and licensed to administer medications under the supervision of an

RN. RN-level education and the scope of practice include assessment of health history,

focused physical assessment, and teaching about study results.

23. The health care provider asks the nurse to evaluate whether a patient‗s angioedema has responded to prescribed therapies. Which assessment would 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.

ANS: C. Observe for swelling of the patient‗s lips and tongue

Angioedema is characterized by swelling of the eyelids, lips, and tongue. Wheal and flare

lesions, clear nasal drainage, and hypotension and tachycardia are characteristic of other

allergic reactions.

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. The patient-donor crossmatch is positive.

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.

25. A patient who is receiving immunotherapy has just received an allergen injection. Which finding is most important to communicate to the health care provider?

a. The patient‗s IgG level is increased.

b. There is redness and swelling at the injection site.

c. There is a 2-cm wheal at the site of the injection.

d. The patients symptoms did not improve in 2 months.

ANS: C. There is a 2-cm wheal at the site of the injection.

A local reaction larger than quarter size may indicate that a decrease in the allergen dose is

needed. An increase in IgG shows that the therapy is effective. Redness and swelling at the

site are not unusual. Because immunotherapy usually takes 1 to 2 years to achieve an effect,

an improvement in the patient‗s symptoms is not expected after a few months.

(book questions) 1. A patient with a low number of monocytes would have a decreased ability to

a. stimulate the production of T and B lymphocytes.

b. make antibodies after exposure to foreign substances.

c. bind antigens and stimulate natural killer cell activation.

d. capture antigens by phagocytosis and present them to lymphocytes.

1. d. capture antigens by phagocytosis and present them to lymphocytes.

(book questions) 2. Newborns are protected for the first 3 months of life from bacterial infections because of the maternal transmission of

a. IgA.

b. IgE.

c. IgG.

d. IgM.

2. c. IgG.

(book questions) 3. In a type I hypersensitivity reaction the primary immunologic disorder appears to be

a. binding of IgG to an antigen on a cell surface.

b. deposit of antigen-antibody complexes in small vessels.

c. release of cytokines used to interact with specific antigens.

d. release of chemical mediators from IgE-bound mast cells and basophils.

3.d. release of chemical mediators from IgE-bound mast cells and basophils.

(book questions) 4. The nurse would be alerted to possible anaphylactic shock after a patient has received IM penicillin by the development of

a. edema and itching at the injection site.

b. sneezing and itching of the nose and eyes.

c. a wheal-and-flare reaction at the injection site.

d. chest tightness and production of thick sputum.

4.a. edema and itching at the injection site.

(book questions) 5. The nurse tells a friend who asks him to administer his allergy shots that

a. it is illegal for nurses to administer injections outside of a medical setting.

b. he is qualified to do it if the friend has epinephrine in an injectable syringe provided with his extract.

c. avoiding the allergens is a more effective way of controlling allergies, and allergy shots are not usually effective.

d. immunotherapy should only be administered in a setting where emergency equipment and drugs are available.

5. d. immunotherapy should only be administered in a setting where emergency equipment and drugs are available.

(book questions) 6. A patient is undergoing plasmapheresis for treatment of systemic lupus erythematosus. The nurse explains that plasmapheresis is used in treatment to

a. remove T lymphocytes in her blood that are producing antinuclear antibodies.

b. remove normal particles in her blood that are being damaged by autoantibodies.

c. exchange her plasma that contains antinuclear antibodies with a substitute fluid.

d. replace viral-damaged cellular components of her blood with replacement whole blood.

6. c. exchange her plasma that contains antinuclear antibodies with a substitute fluid.

(book questions) 7. The most common cause of secondary immunodeficiencies is

a. drugs.

b. stress.

c. malnutrition.

d. human immunodeficiency virus.

7. a. Drugs

(book questions) 8. Association between HLA antigens and diseases is most often found in what disease conditions?

a. Cancers

b. Infectious diseases

c. Neurologic diseases

d. Autoimmune disorders

8. d. Autoimmune disorders

(book questions) 9. What accurately describes rejection after transplantation?

a. Hyperacute rejection can be treated with antimetabolites.

b. Acute rejection can be treated with sirolimus or tacrolimus.

c. Chronic rejection can be treated with tacrolimus or cyclosporine.

d. Hyperacute reaction can be avoided if crossmatching is done before transplantation.

9. d. Hyperacute reaction can be avoided if crossmatching is done before transplantation.

(book questions) 10. In a person having an acute rejection of a transplanted kidney, what would help the nurse understand the course of events? (select all that apply)

a. A new transplant should be considered.

b. Acute rejection can be treated with mycophenolate.

c. Repeated episodes of acute rejection can lead to chronic rejection.

d. Corticosteroids are the most successful drugs used to treat acute rejection.

e. Acute rejection is common after a transplant and can be treated with drug therapy.

10. b, c, e.

b. Acute rejection can be treated with mycophenolate.

c. Repeated episodes of acute rejection can lead to chronic rejection.

e. Acute rejection is common after a transplant and can be treated with drug therapy.