Nokea
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.
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A student nurse is learning about the types of different cells involved in the inflammatory response. Which principles does the student learn?
- A. Basophils are only involved in the general inflammatory process
- B. Basophils are only involved in the general inflammatory process
- C. Macrophages participate in many episodes of phagocytosis
- D. Monocytes turn into macrophages after they enter body tissues
- E. Neutrophils can only take part in one episode of phagocytosis
Correct Answer: B,C,D,E
Rationale: Basophils are involved in both general inflammation and allergic/hypersensitivity responses. Macrophages can perform multiple phagocytosis episodes, monocytes differentiate into macrophages in tissues, and neutrophils are limited to one phagocytosis event.
A nurse is assessing any older client for the presence of infection. The clients temperature is 97.6 F (36.4 C). What response by the nurse is best?
- A. Assess the client for more specific signs
- B. Conclude that an infection is not present
- C. Conclude that an infection is not present.
- D. Request that the provider order blood cultures.
Correct Answer: A
Rationale: Because older adults have decreased immune function, including reduced neutrophil function, fever may not be present during an episode of infection. The nurse should assess the client for specific signs of infection.
A clinic nurse is working with an older client. What assessment is most important for preventing infections in this client?
- A. Assessing vaccination records for booster shot needs
- B. Encouraging the client to eat a nutritious diet
- C. Instructing the client to wash minor wounds carefully
- D. Teaching hand hygiene to prevent the spread of microbes
Correct Answer: A
Rationale: Older adults may have insufficient antibodies against microbes to which they have been exposed. Assessing vaccination records ensures they receive necessary booster shots to maintain immunity.
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.
A nurse is assessing a client for acute rejection of a kidney transplant. What assessment finding requires the most rapid communication with the provider?
- A. Blood urea nitrogen (BUN) of 18 mg/dL
- B. Cloudy, foul-smelling urine
- C. Creatinine of 3 mg/dL
- D. Urine output of 340 mL/8 hr
Correct Answer: C
Rationale: A creatinine level of 3 mg/dL is elevated, indicating possible kidney dysfunction and a sign of acute rejection, requiring urgent communication with the provider.