Nokea
The nurse is admitting a patient to the hospital with a diagnosis of acute rejection of a kidney transplant. Which of the following actions should the nurse anticipate implementing?
- A. Administration of immunosuppressant medications
- B. Insertion of an arteriovenous graft for hemodialysis
- C. Placement of the patient on the transplant waiting list
- D. Drawing blood for human leukocyte antigen (HLA) and ABO compatibility
Correct Answer: A
Rationale: Acute rejection is treated with the administration of additional immunosuppressant drugs such as corticosteroids. Because acute rejection is reversible, there is no indication that the patient will require another transplant, hemodialysis, or HLA/ABO testing.
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The nurse is caring for a patient who had a bone marrow transplant for treatment of leukemia and has developed a skin rash 10 days after the transplant. The nurse recognizes this reaction as an indication of which of the following?
- A. Donor T cells are attacking the patient's skin cells.
- B. The patient's antibodies are rejecting the donor bone marrow.
- C. The patient is experiencing a delayed hypersensitivity reaction.
- D. The patient will need treatment to prevent hyperacute rejection.
Correct Answer: A
Rationale: 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.
Which of the following adverse effects is related to cyclosporine administration?
- A. Nephrotoxicity
- B. Aseptic necrosis
- C. Peptic ulcer
- D. Leukopenia
Correct Answer: A
Rationale: Nephrotoxicity is the most severe adverse effect of cyclosporine. Aseptic necrosis, peptic ulcer, and leukopenia are all adverse effects of the use of corticosteroids, for example, prednisone.
The nurse is completing an assessment and health history with a patient. Which of the following statements made by the patient should alert the nurse to a possible immunodeficiency disorder?
- A. I take one baby Aspirin every day to prevent stroke.'
- B. I usually eat eggs or meat for at least two meals a day.'
- C. I had my spleen removed many years ago after a car accident.'
- D. I had a chest x-ray 6 months ago when I had walking pneumonia.'
Correct Answer: C
Rationale: Splenectomy increases the risk for septicemia from bacterial infections. The patient's protein intake is good and should improve immune function. Daily Aspirin use does not impact immune function. A chest x-ray does not have enough radiation to suppress immune function.
The nurse is obtaining a health history from a patient who works as a laboratory technician and learns that the patient has a history of allergic rhinitis, asthma, and multiple food allergies. Which of the following actions is most important for the nurse to implement?
- A. Encourage the patient to carry an epinephrine kit in case a type IV allergic reaction to latex develops.
- B. Advise the patient to use oil-based hand creams to decrease contact with natural proteins in latex gloves.
- C. Document the patient's allergy history and be alert for any clinical manifestations of a type I latex allergy.
- D. Recommend that the patient use vinyl gloves instead of latex gloves in preventing bloodborne pathogen contact.
Correct Answer: C
Rationale: The patient's allergy history and occupation indicate a risk for development of latex allergy, and the nurse should be prepared to manage any symptoms that occur. Epinephrine is not an appropriate treatment for contact dermatitis that is caused by a type IV allergic reaction to latex. Oil-based creams will increase the exposure to latex from latex gloves. Vinyl gloves are appropriate to use when exposure to body fluids is unlikely.
To determine whether a patient's angioedema has responded to prescribed therapies, which of the following actions should the nurse take first?
- A. Ask about any clear nasal discharge.
- B. Obtain blood pressure and heart rate.
- C. Check for swelling of the lips and tongue.
- D. Assess extremities for wheal and flare lesions.
Correct Answer: C
Rationale: Angioedema is characterized by swelling of the eyelids, lips, and tongue. Wheal and flare lesions, clear nasal drainage, and hypotension and tachycardia are characteristics of other allergic reactions.