Immune System Disorders and Transplantation

Question 1

After several months of testing a patient is placed on the United Network for Organ Sharing (UNOS) waiting list for a kidney transplant. The patient says, “How long do you think it will take for me to get a kidney?” Which nursing response is indicated?

1. “Most people get a kidney within the first 6 months of being on the list.”
2. “It depends upon how much you are willing to pay for a kidney.”
3. “It is impossible to predict when your kidney will be available.”
4. “Some people die waiting for a kidney.”

Answer 1

Correct Answer: 3

Rationale 1: Only about 17% of people receive a kidney in the first 6 months of being listed.

Rationale 2: The Uniform Anatomical Gift Act prohibits trafficking in organs for a profit.

Rationale 3: Waiting time is impossible to predict and is related to such variables as body size, blood type, and antibody levels.

Rationale 4: This is a true statement, but is not therapeutic.

Question 2

A patient awaiting a kidney transplant has O blood type. The nurse would explain that the patient’s kidney can come from someone with which blood type?

1. Only O
2. B or O
3. A or O
4. A, B, or O

Answer 2

Correct Answer: 1

Rationale 1: If an organ recipient’s blood type is O, the only blood type of an organ donator that the recipient can receive must also be O.

Rationale 2: If the organ recipient has the blood type of B, organs from donors with B or O can be received.

Rationale 3: An organ recipient with the blood type A can receive an organ from a donor with the blood type of either A or O.

Rationale 4: If the recipient has the blood type of AB, organs from donors with A, B, or O can be received.

Question 3

A patient tells the nurse that he thought he had a varicella vaccine as a child. His daughter has just developed varicella. What information should the nurse provide? Select all that apply.

1. “Since you were vaccinated you won’t contract varicella from your daughter.”
2. “Your innate immunity will protect you from contracting this disease.”
3. “It is dangerous to give a second injection of vaccines.”
4. “You may need an injection to boost your immunity.”
5. “We can check your blood titer to check your immunity.”

Answer 3

Correct Answer: 4,5

Rationale 1: Vaccinations do not always provide life-long immunity.

Rationale 2: The immunity that this patient may have against varicella is not innate immunity.

Rationale 3: There is no indication that a second injection of vaccines is dangerous if it is needed.

Rationale 4: In some cases, there is need for a second injection.

Rationale 5: Antibody titers can be compared to pre-established norms to see if repeated immunizations are necessary.

Question 4

The transplant team works to decrease the number of posttransplant infections due to iatrogenic causes. Which nursing intervention would support this goal?

1. Maintaining strict sterile technique with all invasive procedures
2. Teaching the patient to restrict the number of visitors the patients have after returning home
3. Identifying potential source of infection from patient history
4. Assisting with careful screening of donors

Answer 4

Correct Answer: 1

Rationale 1: Iatrogenic infections are those acquired in the hospital following transplantation. Vigilance regarding hand hygiene and sterile technique for invasive procedures can help reduce these infections.

Rationale 2: If a contagion is brought into the home by visitors it is still considered community acquired.

Rationale 3: Infections can reactivate from a dormant state. The team should look for these potential infections during pretransplant evaluations.

Rationale 4: Infections that occur because the donor organ or tissues were infected are called donor-derived infections.

Question 5

A patient recovering from liver transplant surgery is being instructed on the long-term use of steroid medication. Which education should the nurse provide?

1. Abdominal pain and nausea are side effects and are expected.
2. There are no major side effects associated with this medication.
3. This medication helps prevent organ rejection but you must report any vision changes and bone pain and be tested for diabetes regularly.
4. This medication works for a few months and will be discontinued.

Answer 5

Correct Answer: 3

Rationale 1: Abdominal pain and nausea are not expected side effects of glucocorticoid therapy.

Rationale 2: There are major side effects of steroid medications.

Rationale 3: Steroid therapy is useful for prevention of rejection and is used in rescue therapy for organ rejection; however, long-term use is associated with severe bone disorders, diabetes mellitus, and cataracts. The patient should be instructed to report any vision changes and bone pain and should be tested regularly for the onset of diabetes.

Rationale 4: The patient will most likely be on this medication for a very long time, perhaps for life.

Question 6

A patient is diagnosed with a low red blood cell count. The nurse should assess this patient for which finding?

1. History of fractures
2. Carbohydrate intake
3. Location of joint replacements
4. Renal functioning

Answer 6

Correct Answer: 4

Rationale 1: A history of fractures will not impact the patient’s current red blood cell formation.

Rationale 2: Production of red blood cells requires certain levels of adequate nutrients which include protein, multivitamins, and nutrients. The patient’s carbohydrate intake will not affect red blood cell production.

Rationale 3: Even though red blood cells do originate in the marrow of the ribs, sternum, and femur, joint replacements will most likely not impact red blood cell formation.

Rationale 4: Red blood cells arise from the myeloid cell line in the red bone marrow and mature in the blood or spleen. Erythrocyte production is tightly regulated by erythropoietin, a circulating hormone that is primarily produced by the kidneys. It is believed that erythropoietin may be produced in the renal tubular cells, which are major consumers of oxygen that are particularly sensitive to lowering oxygen levels. In a patient with a low red blood cell count, the patient’s renal function should be further assessed.

Question 6

A patient is concerned that the disease that has affected his horses will cause him to become ill. What information should the nurse provide?

1. “You will probably contract the same illness but in a milder form.”
2. “Many illnesses are species specific and it is not likely that you will contract the same illness as your horses.”
3. “All illnesses can be transmitted between animals and humans, so I am glad you came in to be checked.”
4. “There are vaccinations against diseases caused by horses. I would talk with the veterinarian.”

Answer 6

Correct Answer: 2

Rationale 1: There is no way of knowing if the patient will contract the same illness as the horses or if the illness will be in a milder form.

Rationale 2: Innate immunity is species specific which means that human beings are immune to a variety of diseases to which certain animals are susceptible, and vice versa. The nurse should explain this concept to the patient.

Rationale 3: All illnesses cannot be transmitted between animals and humans.

Rationale 4: It is unknown if there is a vaccine to provide immunity against diseases caused by horses.

Question 6

The mother of a young child tells the nurse that when she was breastfeeding her baby, he never had any colds or infections but now that he is weaned, he seems to be sick all of the time. What should the nurse explain to the mother?

1. The breast milk provided passive immunity to the baby that he no longer is receiving.
2. The child should be immunized to prevent these common illnesses.
3. Some children are just prone to getting more infections than others.
4. Most babies won’t get sick until they are past the age of 12 months.

Answer 6

Correct Answer: 1

Rationale 1: Passive immunity is a temporary immunity involving the transfer of antibodies from one individual to another or from some other source to an individual. An infant receives passive immunity both in utero and from breast milk.

Rationale 2: There are no immunizations against many of these common illnesses.

Rationale 3: This information is not accurate and should not be provided to the mother

Rationale 4: This information is not accurate and should not be provided to the mother.

Question 6

A 55-year-old patient tells the nurse that he seems to be getting “more colds” as he gets older. Which possible explanation would the nurse have for this observation?

1. Aging causes the immune system to have difficulty determining self from non-self cells.
2. With aging, the body has increased difficulty recognizing mutated cells.
3. The thymus gland shrinks with aging, reducing the maturation and differentiation of T cells needed to fight infections.
4. The thyroid gland begins to malfunction after the 4th decade of life.

Answer 6

Correct Answer: 3

Rationale 1: The ability of the immune system to discriminate between antigens that are “self” from those that are “non-self” would explain the increased incidence of autoimmune diseases in middle age and older patients, but not increase in infectious diseases.

Rationale 2: The body’s immune system becoming less efficient at recognizing and destroying mutated cells can explain the increased incidence of cancer in the older adult, not increase in infectious diseases.

Rationale 3: The function of the immune system declines with age. The thymus gland, where T lymphocytes mature and differentiate, begins to atrophy early in life and continues to shrink until a person reaches middle age. Although T lymphocytes continue to be produced, their maturation and differentiation into the various functional T cells decreases. This places the older patient at higher risk for increased frequency and severity of infections accompanied by a decreased ability to resolve the infection.

Rationale 4: The thyroid gland plays no significant role in immunity.

Question 6

A patient hospitalized for treatment of a mediastinal malignancy is at risk for developing superior vena cava (SVC) syndrome. The nurse would monitor for the development of which signs of this disorder? Select all that apply.

1. Headache
2. Distended neck veins
3. Flushed face
4. Decreased pedal pulses
5. Pain in the lower back

Answer 6

Correct Answer: 1,2,3

Rationale 1: SVC syndrome causes decreased venous drainage in the upper body. Headache is a finding associated with this syndrome.

Rationale 2: SVC syndrome results in decreased venous drainage in the upper trunk. The nurse should monitor for distention of neck veins.

Rationale 3: SVC syndrome results in decreased venous drainage in the upper trunk. Flushing of the face is a symptom.

Rationale 4: SVC syndrome involves the upper trunk and is not associated with the lower extremities.

Rationale 5: SVC syndrome is not associated with back pain. Spinal cord compression is an oncologic emergency that causes back pain.

Question 6

A patient received allogeneic hematopoietic stem cell transplantation 2 days ago. Which information should the nurse provide?

1. “Your body is accepting the transplanted cells so you should be feeling a lot better.”
2. “Your body is making normal hematopoietic cells.”
3. “You feel so bad because the transplanted cells are attacking your tissues, but that is normal and will pass.”
4. “You may not feel well today and we need to protect you from exposure to any infections.”

Answer 6

Correct Answer: 4

Rationale 1: This is a period in which the patient will not feel “much better.”

Rationale 2: It can take up to 5 weeks for the body to make normal hematopoietic cells and not 2 days.

Rationale 3: If graft vs. host disease is occurring the patient will feel sick but GVHD does not “pass” nor is it normal.

Rationale 4: Within 2 to 3 days after the transplant, the patient’s bone marrow function drops to its lowest level, placing the patient at significant risk for infection.

Question 7

A patient is scheduled to have his tonsils removed. The nurse realizes that this procedure could result in deficiency of which immunoglobulin?

1. Immunoglobulin D
2. Immunoglobulin A
3. Immunoglobulin E
4. Immunoglobulin G

Answer 7

Correct Answer: 2

Rationale 1: Immunoglobulin D is a trace antibody found primarily in the blood.

Rationale 2: Immunoglobulin A protects mucous membranes from invading organisms and is found in the tonsils.

Rationale 3: Immunoglobulin E plays a role in the allergic response and is extremely powerful even though it is present in the body in very small quantities.

Rationale 4: Immunoglobulin G is the chief immunoglobulin and is produced on a secondary exposure to an antigen.

Question 8

A patient in the acute care unit has developed neutropenia. A nurse would identify which history as a possible etiology of this condition?

1. The patient had symptoms of an untreated bacterial infection for a week prior to admission.
2. The patient’s blood sugar was 120 mg/dL on admission.
3. The patient’s lab work reveals a vitamin C deficiency.
4. The patient has been receiving chemotherapy treatment for lung cancer.

Answer 8

Correct Answer: 4

Rationale 1: Untreated bacterial infections are not implicated in the development of neutropenia.

Rationale 2: Hyperglycemia is not associated with the development of neutropenia.

Rationale 3: Neutropenia can occur with a vitamin B12 deficiency, but is not found with vitamin C deficiency.

Rationale 4: Neutropenia caused by decreased production of neutrophils can occur as a result of bone marrow suppression after chemotherapy.

Question 9

A patient was admitted through the emergency department with fractures of the skull, ribs, and both femurs sustained from a motor vehicle accident. The nurse provides care based upon changes in which pathophysiological process?

1. Formation of red blood cells
2. Cellular and humoral immune responses
3. Formation of plasma
4. Antigen–antibody formation

Answer 9

Correct Answer: 1

Rationale 1: Blood cells are formed in the bone marrow which exists within all bones. Because the patient sustained fractures to the skull, ribs, and both femurs, red blood cell formation will be impacted.

Rationale 2: Cellular and humoral immune responses occur in secondary lymphoid organs such as the tonsils, adenoids, lymph nodes, and spleen. This patient’s injuries are not focused in these areas.

Rationale 3: Plasma is a clear fluid that remains once all of the blood cells are removed. Formation of plasma should not be affected by these injuries.

Rationale 4: Antigen–antibody response is what occurs when an infectious organism is introduced into the body. The ability to mount this response will continue despite these injuries.

Question 10

The nurse is caring for a patient who will be an organ donor. Which nursing intervention is indicated to protect endocrine function?

1. Provide bolus of levothyroxine, Solu-Medrol, insulin, and 50 percent dextrose followed by continuous levothyroxine intravenous infusion.
2. Administer salt poor intravenous fluid.
3. Administer blood transfusion.
4. Provide intravenous dopamine.

Answer 10

Correct Answer: 1

Rationale 1: Management of the patient who is an identified organ donor includes maintaining endocrine stability. To do this, the thyroid protocol should be implemented which is to provide a bolus of levothyroxine, Solu-Medrol, insulin, and 50 percent dextrose followed by a continuous levothyroxine intravenous infusion.

Rationale 2: Salt poor intravenous fluids are used to manage the renal/fluid/electrolyte status.

Rationale 3: Blood transfusions are used to manage the hematopoietic status.

Rationale 4: Intravenous dopamine is used to manage the patient’s hemodynamic status.

Question 11

A patient is admitted with a leg wound with a large amount of pus exudate. The nurse assesses that which part of the immune process is functioning?

1. The complement system causing cellular destruction
2. The natural killer lymphocytes circulating through the lymph
3. The neutrophils arriving at the wound as the first line of defense
4. The macrophages circulating in the blood

Answer 11

Correct Answer: 3

Rationale 1: The complement system is an immune mechanism that resembles the blood coagulation cascade by progressing through several sequential stages, each contributing to the immune response and resulting in cellular destruction or cytolysis. Activation of the complement system does not result in pus formation.

Rationale 2: Natural killer lymphocytes protect the body from pathologic cells such as microbes and cancer cells through cytolytic activities and secretion of cytokines. They do not produce pus.

Rationale 3: Neutrophils are responsible for the formation of pus. As they die, the neutrophil-degrading enzymes are released, causing breakdown and liquefaction of local cells as well as foreign substances. This forms pus, a thin liquid residue that is an important indicator of inflammation.

Rationale 4: Mobile macrophages circulate in the blood supply and migrate out of the vessels into the tissues when required through the process of chemotaxis. They do not produce pus.

Question 11

A patient tells the nurse that chronic kidney disease is “in his family” and his father died within a few months after having a kidney transplant in the late 1940s. What information should the nurse provide?

1. “Your chances of a successful transplant depend upon finding a healthy family member who is a match and will agree to provide an organ.”
2. “The most successful transplants have always been the heart and lungs.”
3. “Many of the earlier failures of kidney transplants had to do with suturing technique.”
4. “Medications to prevent problems associated with organ transplantation are now widely available.”

Answer 11

Correct Answer: 4

Rationale 1: Many non-family transplants are performed and are successful.

Rationale 2: Transplanting the heart and lungs did not receive the focus of transplantable organs until the 1980s. There is no evidence that transplant of these organs is more successful than transplant of other organs.

Rationale 3: The major problem associated with transplant has always been rejection.

Rationale 4: Cyclosporine and other antirejection drugs are now available and have made transplant surgeries much more successful.

Question 12

A wound on a patient’s leg has stopped bleeding. The nurse would attribute this to which physiologic occurrence?

1. Tumor necrosis factor has sealed the wound.
2. Neutrophils have invaded the wound.
3. Macrophages have been released into the general circulation.
4. Platelets retracted the clot, reducing leakage.

Answer 12

Correct Answer: 4

Rationale 1: Tumor necrosis factor will not seal a wound.

Rationale 2: Neutrophils do not impact the amount of bleeding from a wound.

Rationale 3: Macrophages in the general circulation do not impact the amount of bleeding from a wound.

Rationale 4: Shortly after bleeding has stopped and the clot has formed, it retracts, drawing the torn vessel walls into closer proximity, reducing leakage. Clot retraction is largely a function of platelets.

Question 13

A patient being conditioned for hematopoietic stem cell transplantation will receive muromonab-CD3 (Orthoclone OKT3). Which medications will the nurse anticipate administering before this medication is given? Select all that apply.

1. Acetaminophen
2. Vitamin C
3. Penicillin
4. Diphenhydramine
5. Glucocorticoids

Answer 13

Correct Answer: 1,4,5

Rationale 1: Acetaminophen is given prophylactically to prevent “first-dose effect.”

Rationale 2: Vitamin C is not standardly administered before this drug.

Rationale 3: Penicillin is not standardly given before this drug.

Rationale 4: Diphenhydramine is given prophylactically to prevent “first-dose effect.”

Rationale 5: Glucocorticoids are administered prophylactically to prevent “first-dose effect.”

Question 14

A patient receiving a blood transfusion begins gasping for breath 10 minutes into the transfusion. The nurse realizes the patient is experiencing which type of hypersensitivity response?

1. Type I
2. Type III
3. Type IV
4. Type II

Answer 14

Correct Answer: 4

Rationale 1: A type I hypersensitivity response occurs after repeated exposure to an allergen which causes an allergen–antigen response.

Rationale 2: A type III hypersensitivity response is also an allergen–antigen response, however the complexes are found in tissues. Organ rejection is an example of this type of response.

Rationale 3: A type IV hypersensitivity response is a delayed response seen after an insect bite or with poison ivy.

Rationale 4: A transfusion reaction is a major example of a type II hypersensitivity response. The reaction will occur within minutes of beginning the transfusion and is an emergency.

Question 14

It has been determined that a patient who received hematopoietic stem cell transplantation is having poor functioning of the graft. The nurse would prepare the patient for which intervention?

1. Administration of high dose corticosteroids
2. A second stem cell infusion
3. Administration of platelets
4. Surgery to remove the graft

Answer 14

Correct Answer: 2

Rationale 1: Corticosteroids are included in the management of the patient experiencing graft versus host disease.

Rationale 2: If the initial graft fails a second stem cell infusion may be possible.

Rationale 3: The administration of platelets or red blood cells would be indicated in the management of the patient experiencing severe pancytopenia.

Rationale 4: Surgery to remove a stem cell graft is not possible.

Question 15

A patient with neutropenia develops a fever. Which nursing action is most important?

1. Discuss the finding with the primary care provider.
2. Encourage oral fluids.
3. Review the medical record for trending.
4. Document this expected finding.

Answer 15

Correct Answer: 1

Rationale 1: Febrile neutropenia is a potentially life-threatening event and must be treated rapidly. This occurrence should be discussed with the primary care provider with the expectation of prescriptions for antibiotics or other treatments.

Rationale 2: Encouraging oral fluids is not a sufficient nursing action in this situation.

Rationale 3: The nurse should take action beyond review of the medical record.

Rationale 4: Fever is not an expected finding and is an especially troubling complication in a patient with neutropenia.

Question 16

A patient is admitted with left lower thoracic rib injuries. The nurse realizes this injury could result in which problem for this patient?

1. Decrease in platelet maturation
2. Decreased availability of B cells
3. Reduction in T cell formation
4. Reduction in filtering of foreign matter in the blood

Answer 16

Correct Answer: 2

Rationale 1: Platelet maturation does not occur in this area.

Rationale 2: The spleen sits behind the 9th, 10th, and 11th left ribs and serves three functions: destroy injured or worn out red blood cells, store extra blood for use by the body, and store B cells. With an injury to the left lower thoracic rib area, the patient could have an injury to the spleen.

Rationale 3: There is a possibility of splenic injury. Splenic injuries do not cause a reduction in T cell formation.

Rationale 4: Lymph tissue is where the blood is filtered of foreign matter.

Question 18

A female patient is concerned after learning that a person with whom she had a casual sexual encounter has been diagnosed as being HIV positive. Which other patient statement would the nurse evaluate as significant?

1. “I have not felt bad since the possible exposure.”
2. “We were only together for about a week and had sex 3 or 4 times.”
3. “I did have a cold and sore throat last week, but it has cleared up without problems.”
4. “I had a normal period just a few days after we broke up.”

Answer 18

Correct Answer: 3

Rationale 1: There is a clinical latency period or asymptomatic stage that is generally present at the beginning of infection. The fact that the patient has not been symptomatic is not significant.

Rationale 2: The number of exposures is not significant in that infection can occur with one exposure.

Rationale 3: Within about 3 to 6 weeks after exposure to the virus, a transient flu-like or mononucleosis-like disease may occur.

Rationale 4: The presence of normal menses does not decrease the risk of infection.

Question 19

A patient, recovering from skin grafts to the arm because of burn injuries, is demonstrating an increase of drainage, bleeding, and edema. The nurse prepares to treat which complication?

1. Arthus reaction
2. Serum sickness
3. Type I hypersensitivity reaction
4. Type IV hypersensitivity reaction

Answer 19

Correct Answer: 1

Rationale 1: The Arthus reaction is a localized skin reaction in which antigen-antibody complexes form in vessel walls, triggering an inflammatory response in the vessels. The reaction onset is relatively rapid, usually within 1 hour of exposure, and peaks within 6 to 12 hours. The clinical manifestations are those caused by the inflammatory response and include leaking of fluid causing edema and hemorrhage.

Rationale 2: Serum sickness is a systemic type III hypersensitivity response.

Rationale 3: A type I hypersensitivity reaction occurs after repeated exposure to an allergen which causes an allergen–antigen response.

Rationale 4: A type IV hypersensitivity reaction is a delayed response seen after an insect bite or with poison ivy.

Question 20

An elderly patient admitted with malnutrition begins to demonstrate signs of pneumonia. The nurse would explain which possible etiology of this pneumonia?

1. There is a lack of nutrients to support immune function.
2. Insufficient fluid intake has allowed bacteria to grow.
3. The patient’s malnutrition resulted from poor living conditions making infection more likely.
4. Poor nutrition has resulted in a deficiency of vitamin C.

Answer 20

Correct Answer: 1

Rationale 1: Malnutrition affects the immune system because calories and protein are needed to form and maintain the T cells and immunoglobulins.

Rationale 2: An insufficient fluid intake could exacerbate the symptoms of pneumonia but not cause the illness.

Rationale 3: There is no evidence to support the presence of poor living conditions.

Rationale 4: Vitamin C deficiency is not implicated in the development of pneumonia.

Question 21

The nurse is preparing for oculocephalic reflex testing of a patient who may be brain dead. Which equipment should the nurse gather? Select all that apply.

1. Reflex hammer
2. Cold water
3. Syringe
4. Hydrogen peroxide
5. A tongue blade

Answer 21

Correct Answer: 2,3

Rationale 1: A reflex hammer is not used in the determination of oculocephalic reflex.

Rationale 2: The oculocephalic test requires instillation of cold water into the patient’s ear.

Rationale 3: The oculocephalic test requires a syringe.

Rationale 4: Hydrogen peroxide is not used to test the oculocephalic reflex.

Rationale 5: A tongue blade is not used to test the oculocephalic reflex.

Question 22

The nurse is caring for a patient recovering from a kidney transplant. Which information should the nurse provide to this patient?

1. “You may have a graft site leak, so do not eat or drink anything until I talk to the surgeon.”
2. “I am going to slow down your IV fluids to see if that brings your blood pressure down.”
3. “It is probably going to be necessary to give you some fresh frozen plasma.”
4. “Hypertension is a common problem after surgery, so I will be giving you the antihypertensive medication your surgeon ordered in case this occurred.”

Answer 22

Correct Answer: 4

Rationale 1: There is not enough information to support a graft site leak.

Rationale 2: Reducing IV fluids is not likely to be a sufficient intervention to control hypertension in this patient.

Rationale 3: Administration of fresh frozen plasma, which would expand the patient’s circulating blood volume, is not indicated.

Rationale 4: Hypertension is a common problem in the kidney transplant patient. This condition can be exacerbated during the postoperative recovery period because of fluid volume imbalances precipitated by the high volume of IV fluids used to maintain a high urine flow. Antihypertensive agents may be ordered preoperatively and postoperatively to maintain the blood pressure within an acceptable range for the patient.

Question 23

A patient tells the nurse that he had a tuberculin test several months ago and the site of injection became very red and inflamed. How should the nurse interpret this information?

1. This Arthus reaction is common with tuberculin tests.
2. This type IV hypersensitivity response indicates the tuberculin test was positive.
3. Since this type II hypersensitivity response occurred, the patient should never have another tuberculin test.
4. The patient will require chest x-ray confirmation of this type I hypersensitivity response.

Answer 23

Correct Answer: 2

Rationale 1: An Arthus reaction is a localized skin reaction in which antigen–antibody complexes form in vessel walls, triggering an inflammatory response in the vessels. Tuberculin testing does not result in Arthus reaction.

Rationale 2: A type IV hypersensitivity response is seen in the induration of a positive tuberculin test.

Rationale 3: This is not a type II hypersensitivity response.

Rationale 4: This is not a type I hypersensitivity response.

Question 24

The nurse caring for a patient with an infected leg wound realizes that neutrophils and macrophages will arrive to the wound as a part of the natural body response. How would the nurse explain this process to the patient?

1. “Your white blood cells will travel through your lymph system to the wound.”
2. “Chemical signals from the injured tissue help guide the white blood cells to where they are needed.”
3. “Only the white blood cells already in your system will be able to fight this infection.”
4. “The white blood cells attach to red blood cells for transport to the wound.”

Answer 24

Correct Answer: 2

Rationale 1: The white blood cells do not travel through the lymph system.

Rationale 2: Circulating neutrophils and monocytes have to arrive where they are needed and then they must be able to transfer from the blood vessels to the site of injury. After the leukocyte is outside the capillary, it requires guidance to move to the correct location. This is accomplished through chemotaxis, which refers to movement as a result of some type of chemical stimulus.

Rationale 3: Infection stimulates the production of additional white blood cells.

Rationale 4: White blood cells are independent of red blood cells.

Question 25

A patient being treated with isoniazid for tuberculosis develops symptoms of systemic lupus erythematosus (SLE). The patient says, “I can’t believe that I am so sick. First I get TB and now this. What is going to happen to me?” What nursing response is indicated?

1. “You will have to learn to manage both the TB and the SLE.”
2. “Once your TB is cured, we can help you fight the SLE.”
3. “Often the SLE symptoms go away after the TB medication is changed.”
4. “Your immune system must be under a great deal of stress for both of these diseases to develop.”

Answer 25

Correct Answer: 3

Rationale 1: This is not a therapeutic response and should not be used with this patient.

Rationale 2: There is no indication that SLE treatment must be delayed until the TB is cured.

Rationale 3: Drug-induced SLE often resolves upon discontinuation of the drug.

Rationale 4: Immunity is not associated with the development of this patient’s SLE.

Question 26

A patient who received a kidney transplant 2 years ago has been diagnosed with skin cancer. He tells the nurse that he cannot believe that he has cancer since he has already gone through “so much” with the kidney disease. How should the nurse respond to this patient’s statement?

1. “It is unusual for malignancies to develop this long after transplant.”
2. “Patients on long-term medications to prevent organ rejection are at risk for developing cancer.”
3. “At least this cancer will not affect the transplanted kidney.”
4. “Everyone can develop cancer at any time.”

Answer 26

Correct Answer: 2

Rationale 1: Cancers can develop as soon as 6 months after transplant surgery or may not develop for 10 to 15 years after surgery.

Rationale 2: Patients on long-term immunosuppressant therapy are at increased risk for development of some form of malignancy.

Rationale 3: It is unknown whether this cancer, which may be melanoma, will or will not affect the transplanted kidney.

Rationale 4: This is a true statement but does not address this patient’s concerns.

Question 27

A patient tells the nurse that it seems like the only time she gets a cold is when she is under higher than normal stress. What information should the nurse provide?

1. “You probably don’t eat as well when you are under stress.”
2. “You probably don’t rest and sleep as well when your stress is high.”
3. “Stress causes your body to have an autoimmune response.”
4. “Stress increases cortisol which suppresses your immune system.”

Answer 27

Correct Answer: 4

Rationale 1: This is an assumption on the nurse’s part. There is no evidence that a change in nutrient intake exists.

Rationale 2: This is an assumption on the nurse’s part. There is no evidence that lack of sleep and rest exist.

Rationale 3: Colds are not a result of an autoimmune response.

Rationale 4: Cortisol has a direct suppressing effect on the immune system by inhibiting the production of interleukins which stimulate T and B cell production and response.

Question 28

A patient suffered severe trunk and lower extremity injury in a motor vehicle accident. Which injuries would indicate to the nurse that this patient may have dysfunction of normal hemostasis? Select all that apply.

1. Contusion of the spleen
2. Laceration of the liver
3. Femur fractures
4. Bruising of the heart
5. Pneumothorax

Answer 28

Correct Answer: 1,2,3

Rationale 1: The spleen provides storage for platelets. If the spleen is damaged and unable to hold or release platelets, normal hemostasis will be disrupted.

Rationale 2: The liver produces most of the clotting factors so injury would affect normal hemostasis.

Rationale 3: The marrow of long bones support blood cell development. This patient may have disruption of all three cell lines.

Rationale 4: Bruising of the heart should not affect hemostasis.

Rationale 5: Pneumothorax should not affect hemostasis.

Question 29

A patient with an autoimmune disorder says, “I don’t know why this happened to me. I try to exercise and eat well.” How should the nurse respond?

1. “These disorders are usually associated with a vitamin deficiency.”
2. “These problems happen when your body misinterprets normal cells as being foreign and attempts to destroy them.”
3. “It happened because you were exposed to something repeatedly and then the body decided it needed to destroy it.”
4. “Chronic illnesses are the cause of autoimmune disorders.”

Answer 29

Correct Answer: 2

Rationale 1: Autoimmune disorders are not specifically linked to vitamin deficiencies.

Rationale 2: One theory about autoimmunity is that of molecular mimicry. This is when the body will react appropriately to an allergen but then incorrectly identifies normal body tissue as being the same allergen and begins to destroy normal tissue.

Rationale 3: Autoimmune disorders do not occur in response to repeated exposure to an allergen.

Rationale 4: Autoimmune disorders are not linked specifically to chronic illnesses.

Question 30

The patient has developed a “shift to the left.” The nurse would expect which value on the complete blood count?

1. Increased bands
2. Increased eosinophils
3. Decreased lymphocytes
4. Increased monocytes

Answer 30

Correct Answer: 1

Rationale 1: When an infection exists and the body needs neutrophils, the production is increased, but many immature cells or “bands” are released. This release results in a “shift to the left.”

Rationale 2: Eosinophils are not involved in the “shift to the left.”

Rationale 3: A decrease in lymphocytes is not reported as a shift.

Rationale 4: An increase in monocytes is not reported as a shift.

Question 31

A patient is prescribed vitamin B12 injections. What information should the nurse provide when starting this medication?

1. “Vitamin B12 will strengthen the red blood cells’ membranes and prevent them from being damaged so easily.”
2. “Vitamin B12 is needed for normal manufacture of red blood cells.”
3. “Vitamin B12 will increase the ability of your blood to carry oxygen.”
4. “Vitamin B12 helps build the components of white blood cells.”

Answer 31

Correct Answer: 2

Rationale 1: Iron and copper strengthen the plasma membrane.

Rationale 2: Vitamin B12 is one vitamin needed for normal red blood cell synthesis, development of DNA and RNA, and cell maturation.

Rationale 3: Iron increases the oxygen-carrying capacity of the blood.

Rationale 4: Vitamin B12 does not impact white blood cell synthesis.

Question 32

A patient, identified as a potential organ donor, has been diagnosed as brain dead and is being maintained on ventilator support. The nurse is reviewing the patient’s hemodynamic parameters and is concerned about which findings? Select all that apply.

1. Mean arterial pressure 50 mm Hg
2. Central venous pressure 5 mm Hg
3. Serum sodium 145 mEq/L
4. Serum glucose 170 mg/dL
5. Ejection fraction 30%

Answer 32

Correct Answer: 1,5

Rationale 1: There are specific hemodynamic parameters that an adult potential organ donor must meet. The mean arterial pressure should be between 60 and 110 mm Hg.

Rationale 2: Acceptable CVP ranges are 4–12 mm Hg.

Rationale 3: Acceptable serum sodiums are less than 155 mEq/L.

Rationale 4: Acceptable serum glucose readings are less than 180 mg/dL.

Rationale 5: The desirable range for ejection fraction is above 50%.

Question 33

During the post-transplantation period, a patient received tacrolimus (Prograf). The nurse would monitor this patient for the development of which adverse effects? Select all that apply.

1. Congestive heart failure
2. Nausea and vomiting
3. Hyperglycemia
4. Hair loss
5. Infection

Answer 33

Correct Answer: 3,5

Rationale 1: Tacrolimus is not associated with the development of congestive heart failure.

Rationale 2: Tacrolimus is not associated with the development of nausea and vomiting.

Rationale 3: Tacrolimus, a macrolide antibody, has the development of hyperglycemia as a potential adverse reaction.

Rationale 4: Tacrolimus is associated with hirsutism, not hair loss.

Rationale 5: Tacrolimus increases risk for infection.

Question 34

A patient receiving treatment for lymphoma suddenly becomes critically ill and is diagnosed with tumor lysis syndrome. The nurse would review laboratory results for which expected levels? Select all that apply.

1. High serum phosphate
2. Low serum potassium
3. Low serum calcium
4. High uric acid
5. Hyponatremia

Answer 34

Correct Answer: 1,3,4

Rationale 1: Hyperphosphatemia results from rapid destruction of tumor cells.

Rationale 2: Potassium levels will be elevated due to the release of potassium as cells lyse.

Rationale 3: One of the effects of tumor lysis syndrome is a decrease in serum calcium.

Rationale 4: Hyperuricemia is a finding associated with tumor lysis syndrome due to rapid death of tumor cells

Rationale 5: Hyponatremia is not associated with tumor lysis syndrome.

Question 35

The nurse is assessing a patient for altered immunocompetence. Which findings would indicate that the patient is at risk for developing an immunocompetence-associated illness? Select all that apply.

1. Slow wound healing and easy bruising
2. Bursitis and muscle cramps
3. Heart palpitations
4. Heartburn and increased flatus
5. Mouth sores and oral patches

Answer 35

Correct Answer: 1,5

Rationale 1: Assessment data that could indicate an immunocompetence-associated illness includes slow wound healing and easy bruising.

Rationale 2: Bursitis and muscle cramps have little association with altered immunocompetence.

Rationale 3: Heart palpitations have little association with altered immunocompetence.

Rationale 4: Heartburn and increased flatus are not associated with altered immunocompetence.

Rationale 5: Mouth sores and oral patches are related to immunocompetence.

Question 36

The older brother of a patient in renal failure has agreed to donate a kidney. Testing reveals that the brothers are a good match for this procedure. How would the nurse describe this treatment plan?

1. Heterograft living donor
2. Histograft living donor
3. Allograft living donor
4. Isograft living donor

Answer 36

Correct Answer: 3

Rationale 1: Heterograft is the transplantation of tissue between two different species.

Rationale 2: Histograft is not a term used to describe status of the donor. Histocompatible refers to the compatibility between donor and recipient.

Rationale 3: An allograft refers to tissue that is transplanted within the same species. A living donor is someone who agrees to have body parts transplanted into another person while alive. The patient’s brother is an allograft living donor.

Rationale 4: Isograft refers to tissue transplanted between twins.

Question 37

A patient is scheduled to receive a liver for transplantation from a person who has died. The nurse anticipates that the donor has which characteristic?

1. Died of natural causes
2. Experienced cardiac death
3. Died in an automobile accident
4. Experienced brain death

Answer 37

Correct Answer: 4

Rationale 1: It is not possible for the nurse to know if the donor died from natural causes.

Rationale 2: Cardiac death refers to death by cessation of cardiac and respiratory function. This type of death limits the kinds of tissues that can be donated and typically excludes organ donation.

Rationale 3: The method of death is not predictable.

Rationale 4: There are two types of cadaver donors. Organ donors from cadavers who have died from brain death comprise the largest number of implantable organs.

Question 38

A patient’s admission laboratory work reveals a platelet count of 90,000/mcL. Which interventions should the nurse implement? Select all that apply.

1. Implement bleeding precautions.
2. Monitor urine output.
3. Limit the ingestion of green leafy vegetables.
4. Restrict fluids.
5. Review the patient’s medication history.

Answer 38

Correct Answer: 1,5

Rationale 1: Platelets play a crucial role in hemostasis or blood clotting. Since the normal platelet count in an adult is 150,000 to 400,000/mcL, a count of 90,000/mcL means the patient is prone to bleeding. Bleeding precautions should be implemented for this patient.

Rationale 2: There is no evidence that monitoring urine output is an essential part of this patient’s care.

Rationale 3: Green leafy vegetables contain vitamin K which is needed by the liver to form coagulation factors. Since these factors are needed for the coagulation cascade, vitamin K should not be limited in this patient.

Rationale 4: There is no evidence to suggest that fluids should be restricted for this patient.

Rationale 5: Medications can be implicated in low platelet counts, so reviewing medication history is indicated.

Question 39

A patient infected with HIV is being monitored for the development of AIDS. Which characteristics would the nurse monitor? Select all that apply.

1. White blood count
2. CD4+T cell count
3. Presence of recurrent E. coli urinary tract infection
4. Presence of Pneumocystis jiroveci (PJP) infection
5. Presence of cytomegalovirus (CMV)

Answer 39

Correct Answer: 2,4,5

Rationale 1: White blood count does not indicate whether or not AIDS has developed.

Rationale 2: An HIV seropositive patient’s CD4+T count is monitored. If this count is less than 200 cells/mL, a diagnosis of AIDS is made.

Rationale 3: E. coli urinary tract infections are not associated with AIDS.

Rationale 4: PJP is an “AIDS-defining” illness.

Rationale 5: CMV is an “AIDS-defining” illness.

Question 40

The nurse is instructing a patient with a compromised immune status on the signs and symptoms of infections. What should be included in these instructions?

1. Increased sputum production
2. Cloudy urine
3. Irritated oral mucosa
4. Purulent wound drainage

Answer 40

Correct Answer: 3

Rationale 1: The immunocompromised patient will not demonstrate a normal immune response so clinical findings will be different. These patients will not be able to form pus so common infection findings such as increased sputum production will not occur.

Rationale 2: Cloudy urine occurs because of pus. The immunocompromised patient will not demonstrate a normal immune response and may not be able to produce pus.

Rationale 3: Monitoring for infection should focus on the mucous membranes, skin, and lungs, which are the most common sites of infection in this patient population. The nurse should instruct the patient to suspect irritated oral mucosa as a sign of infection.

Rationale 4: Purulent wound drainage is due to the production of pus. The immunocompromised patient may not be able to mount an immune response that will produce pus.

Question 41

A patient being prepared for a heart transplant is concerned that the transplanted organ will not be accepted in his body. What should the nurse consider when formulating a response to this concern?

1. Heart transplants are very successful because of immunosuppressant medication.
2. Today it is more common to do heart–lung transplants.
3. Hearts were the first organs to be transplanted so the technique has been perfected.
4. There are no guarantees since transplants are more successful between twins.

Answer 41

Correct Answer: 1

Rationale 1: Cardiac transplantation is highly successful today, in part because of tissue typing and improved immunosuppressant therapy.

Rationale 2: Both heart and heart–lung transplants are successful today.

Rationale 3: The first transplants were done in the 1950s and were kidney transplants. Heart transplants were first successful in the mid-to-late 1960s.

Rationale 4: Identical twin transplants are the most successful, but much success has also been demonstrated with non-twin transplants.

Question 42

A patient, identified as an organ donor, is diagnosed as being brain dead. The organ procurement organization (OPO) rules that the patient is not a candidate for transplant. The nurse would attribute this decision to which patient history?

1. Experimented with intravenous heroin 20 years prior
2. Being treated for hepatitis B
3. Treated for prostate cancer one year ago
4. Treated for shock

Answer 42

Correct Answer: 2

Rationale 1: Drug abuse many years ago would be considered, but is not the most likely reason this patient’s donor status was denied.

Rationale 2: Transplantation from a donor with active hepatitis B causes risk for transmission to the recipient. This is the most likely reason that this patient’s donor status was denied.

Rationale 3: History of cancer, particularly if the cancer is in remission, is localized, and if not bloodborne does not eliminate a person from being a donor.

Rationale 4: Treatment for shock may or may not result in the organs being unsuitable. The patient would likely be considered as a donor.

Question 43

A patient being admitted for knee surgery says, “Everyone in my office is sick all of the time, but I never get sick.” How would the nurse evaluate this statement?

1. The patient may have a strong antigen–antibody response.
2. This patient’s poorly differentiated histocompatibility antigens may be a problem during postoperative recovery.
3. The patient’s coworkers must have immune system compromise.
4. The patient must have strong passive immunity.

Answer 43

Correct Answer: 1

Rationale 1: Normally, an antibody circulates in the bloodstream until it encounters an appropriate antigen to bind. This binding results in antigen–antibody complexes, or immune complexes. The process of binding is such that the antibody binds to specifically conformed antigenic determinant sites on the antigen, which prevents the antigen from binding to receptors on host cells. The outcome is the host is protected from an infection.

Rationale 2: Histocompatibility antigens are surface antigens which are genetically determined and are proteins found on the surface of a cell. These antigens would not impact the patient’s inability to get colds or other illnesses, nor would they cause complications postoperatively.

Rationale 3: Immune system compromise does result in frequent illnesses, but there is not enough information for the nurse to make this determination.

Rationale 4: Passive immunity is a temporary immunity involving the transfer of antibodies from one individual to another or from some other source to an individual. Passive immunity can be transferred also through vaccination either of antiserum, an antitoxin, or as gamma globulin.

Question 44

Apnea testing is being done on a patient that may be brain dead. During the test the patient develops ventricular tachycardia. What nursing action is indicated? Select all that apply.

1. Reconnect the patient to the ventilator.
2. Draw an immediate arterial blood gas.
3. No action is necessary unless ventricular fibrillation ensues.
4. Allow the patient to die a natural death.
5. Treat the dysrhythmia.

Answer 44

Correct Answer: 1,2,5

Rationale 1: If the patient develops cardiac dysrhythmia during testing, the ventilator should be reestablished.

Rationale 2: If a dysrhythmia develops during testing an immediate arterial blood gas should be drawn.

Rationale 3: Action is necessary.

Rationale 4: Actions besides allowing death to occur are indicated.

Rationale 5: Treatment for this patient should occur just as if brain death was not expected.

Question 45

A patient declared brain dead after cardiac surgery has been accepted as a potential donor. The family has given consent for donation. The nurse providing care to this patient would expect directions from which provider?

1. OPO coordinator
2. Surgeon
3. Cardiologist
4. Hospitalist

Answer 45

Correct Answer: 1

Rationale 1: After consent is obtained the care of the donor is transferred to the OPO and the OPO coordinator directs care.

Rationale 2: At this point the surgeon no longer is associated with the patient’s care.

Rationale 3: At this point the cardiologist is no longer associated with this patient’s care.

Rationale 4: At this point the hospitalist is not associated with the patient’s care.

Question 46

A patient is being evaluated for a kidney transplant. Which individual is most likely the best candidate to donate this organ?

1. A live donor from a donor bank
2. Live kidney transplant from the patient’s spouse
3. Cadaver kidney transplant
4. Live kidney transplant from a brother

Answer 46

Correct Answer: 4

Rationale 1: A person willing to donate a kidney, but who is unrelated to the recipient, is not likely to be a match.

Rationale 2: A spouse may or may not be a match for this donation.

Rationale 3: Cadaver kidneys may or may not match the donor.

Rationale 4: Because full siblings share the same biological parents, they often have some degree of human leukocyte antigen matching. The closer the human leukocyte antigen combination matches between two people, the more the “fingerprint” is recognized as self.