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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.
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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.
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.
Which processes need to be functional and interact with each other for a person to be immunocompetent?
- A. Antibody-mediated immunity
- B. Cell-mediated immunity
- C. Inflammation
- D. Red blood cells
- E. White blood cells
Correct Answer: A,B,C
Rationale: Immunocompetence requires the interaction of antibody-mediated immunity, cell-mediated immunity, and inflammation to effectively protect the body against pathogens.
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.