Nokea
A client has been on dialysis for many years and now is receiving a kidney transplant. The client experiences hyperacute rejection. What treatment does the nurse prepare to facilitate?
- A. Kidney transplant
- B. High-dose steroid administration
- C. Monoclonal antibody therapy
- D. Plasmapheresis
Correct Answer: A
Rationale: Hyperacute rejection occurs within minutes of transplantation and is irreversible. The organ must be removed, and the client returns to dialysis.
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A client has a leg wound that is in the second stage of the inflammatory response. For what manifestation does the nurse assess?
- A. Noticeable rubor
- B. Puniform learning
- C. Swelling and pain
- D. Warmth in the site
Correct Answer: B
Rationale: During the second phase of the inflammatory response, neutrophilia occurs, producing pus, which is assessed as purulent drainage or 'puniform learning' in the context of the question.
A client receiving muromonab-CD3 (Orthoclone OKT3) asks the nurse how the drug works. What response by the nurse is best?
- A. Increases the elimination of T lymphocytes from circulation
- B. It inhibits cytokine production in most lymphocytes
- C. It inhibits cytokine production in most lymphocytes
- D. It prevents the activation of the lymphocytes responsible for rejection
Correct Answer: A
Rationale: Muromonab-CD3 (Orthoclone OKT3) is a monoclonal antibody that increases the elimination of T lymphocytes from circulation, reducing the immune response to prevent transplant rejection.
An older adult has a mild temperature, night sweats, and productive cough. The clients tuberculin test comes back negative. What action by the nurse is best?
- A. Administer pneumonia vaccination
- B. Recognize the client may have a false negative TB test
- C. Teach the client about viral infections
- D. Treat the client as if he or she has tuberculosis (TB)
- E. Tell the client to rest and drink plenty of fluids
Correct Answer: D
Rationale: Due to age-related decreases in T lymphocytes, older adults may have a falsely negative TB test. Given symptoms suggestive of TB, the nurse should treat the client as if they have TB.
The nurse working with clients who have autoimmune diseases understands that what component of cell-mediated immunity is the problem?
- A. CD4+ cells
- B. Covered T cells
- C. Natural killer cells
- D. Suppressor T cells
Correct Answer: D
Rationale: Suppressor T cells (also known as regulatory T cells) help prevent hypersensitivity to one's own cells. Dysfunction in these cells can lead to autoimmune diseases.
The student nurse learns that the most important function of inflammation and immunity is which purpose?
- A. The majority has bacteria of damage vaccines.
- B. Preventing any entry of foreign material
- C. Providing protection against invading organisms
- D. Regulating the process of self-tolerance
Correct Answer: C
Rationale: The purpose of inflammation and immunity is to provide protection to the body against invading organisms, whether they are bacterial, viral, protozoal, or fungal. These systems eliminate, destroy, or neutralize the offending agents.