Medical-Surgical Nursing Assessment and Management of Clinical Problems 9e Chapter 14

Chapter 14: Altered Immune Responses, and Transplantation
Test Bank
MULTIPLE CHOICE
1. The nurse provides discharge instructions to a patient who has an immune deficiency
involving the T lymphocytes. Which screening should the nurse include in the teaching plan
for this patient?
a. Screening for allergies
b. Screening for malignancy
c. Antibody deficiency screening
d. Screening for autoimmune disorders
ANS: B
Cell-mediated immunity is responsible for the recognition and destruction of cancer cells.
Allergic reactions, autoimmune disorders, and antibody deficiencies are mediated primarily by
B lymphocytes and humoral immunity.
DIF: Cognitive Level: Apply (application) REF: 208

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance
2. A new mother expresses concern about her baby developing allergies and asks what the health
care provider meant by passive immunity. Which example should the nurse use to explain
this type of immunity?
a. Early immunization
b. Bone marrow donation
c. Breastfeeding her infant
d. Exposure to communicable diseases
ANS: C
Colostrum provides passive immunity through antibodies from the mother. These antibodies
protect the infant for a few months. However, memory cells are not retained, so the protection
is not permanent. Active immunity is acquired by being immunized with vaccinations or
having an infection. It requires that the infant has an immune response after exposure to an
antigen. Cell-mediated immunity is acquired through T lymphocytes and is a form of active
immunity.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
3. A patient is being evaluated for possible atopic dermatitis. The nurse expects elevation of
which laboratory value?
a. IgE
b. IgA
c. Basophils
d. Neutrophils
ANS: A
Serum IgE is elevated in an allergic response (type 1 hypersensitivity disorders). The
eosinophil level will be elevated rather than neutrophil or basophil counts. IgA is located in
body secretions and would not be tested when evaluating a patient who has symptoms of
atopic dermatitis.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
4. An older adult patient who is having an annual check-up tells the nurse, I feel fine, and I
dont want to pay for all these unnecessary cancer screening tests! Which information should
the nurse plan to teach this patient?
a. Consequences of aging on cell-mediated immunity
b. Decrease in antibody production associated with aging
c. Impact of poor nutrition on immune function in older people
d. Incidence of cancer-stimulating infections in older individuals
ANS: A
The primary impact of aging on immune function is on T cells, which are important for
immune surveillance and tumor immunity. Antibody function is not affected as much by
aging. Poor nutrition can also contribute to decreased immunity, but there is no evidence that
it is a contributing factor for this patient. Although some types of cancer are associated with
specific infections, this patient does not have an active infection.

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
5. A patient who collects honey to earn supplemental income has developed a hypersensitivity to
bee stings. Which statement, if made by the patient, would indicate a need for additional
teaching?
a. I need to find another way to earn extra money.
b. I will get a prescription for epinephrine and learn to self-inject it.
c. I will plan to take oral antihistamines daily before going to work.
d. I should wear a Medic-Alert bracelet indicating my allergy to bee stings.
ANS: C
Because the patient is at risk for bee stings and the severity of allergic reactions tends to
increase with added exposure to allergen, taking oral antihistamines will not adequately
control the patients hypersensitivity reaction. The other patient statements indicate a good
understanding of management of the problem.

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
6. Which teaching should the nurse provide about intradermal skin testing to a patient with
possible allergies?
a. Do not eat anything for about 6 hours before the testing.
b. Take an oral antihistamine about an hour before the testing.
c. Plan to wait in the clinic for 20 to 30 minutes after the testing.
d. Reaction to the testing will take about 48 to 72 hours to occur.
ANS: C
Allergic reactions usually occur within minutes after injection of an allergen, and the patient
will be monitored for at least 20 minutes for anaphylactic reactions after the testing.
Medications that might modify the response, such as antihistamines, should be avoided before
allergy testing. There is no reason to be NPO for skin testing. Results with intradermal testing
occur within minutes.
DIF: Cognitive Level: Apply (application) REF: 213-214

7. The nurse, who is reviewing a clinic patients medical record, notes that the patient missed the
previous appointment for weekly immunotherapy. Which action by the nurse is most
appropriate?
a. Schedule an additional dose that week.
b. Administer the usual dosage of the allergen.
c. Consult with the health care provider about giving a lower allergen dose.
d. Re-evaluate the patients sensitivity to the allergen with a repeat skin test.
ANS: C
Because there is an increased risk for adverse reactions after a patient misses a scheduled dose
of allergen, the nurse should check with the health care provider before administration of the
injection. A skin test is used to identify the allergen and would not be used at this time. An
additional dose for the week may increase the risk for a reaction.

8. While obtaining a health history from a patient, the nurse learns that the patient has a history
of allergic rhinitis and multiple food allergies. Which action by the nurse is most appropriate?
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 patients 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
blood-borne pathogen contact.
ANS: C
The patients allergy history and occupation indicate a risk of developing a latex allergy. The
nurse should be prepared to manage any symptoms that may 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.

9. The nurse teaches a patient diagnosed with systemic lupus erythematosus (SLE) about
plasmapheresis. What instructions about plasmapheresis should the nurse include in the
teaching plan?
a. Plasmapheresis will eliminate eosinophils and basophils from blood.
b. Plasmapheresis will remove antibody-antigen complexes from circulation.
c. Plasmapheresis will prevent foreign antibodies from damaging various body
tissues.
d. Plasmapheresis will decrease the damage to organs caused by attacking T
lymphocytes.
ANS: B
Plasmapheresis is used in SLE to remove antibodies, antibody-antigen complexes, and
complement from blood. T lymphocytes, foreign antibodies, eosinophils, and basophils do not
directly contribute to the tissue damage in SLE.
DIF: Cognitive Level: Understand (comprehension) REF: 218

10. The nurse is caring for a patient undergoing plasmapheresis. The nurse should assess the
patient for which clinical manifestation?
a. Shortness of breath
b. High blood pressure
c. Transfusion reaction
d. Numbness and tingling
ANS: D
Numbness and tingling may occur as the result of the hypocalcemia caused by the citrate used
to prevent coagulation. The other clinical manifestations are not associated with
plasmapheresis.

11. Which statement by a patient would 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 2 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.
ANS: C
Splenectomy increases the risk for septicemia from bacterial infections. The patients protein
intake is good and should improve immune function. Daily aspirin use does not affect immune
function. A chest x-ray does not have enough radiation to suppress immune function.

12. Which patient should the nurse assess first?

a. Patient with urticaria after receiving an IV antibiotic
b. Patient who has graft-versus-host disease and severe diarrhea
c. Patient who is sneezing after having subcutaneous immunotherapy
d. Patient with multiple chemical sensitivities who has muscle stiffness
ANS: C
Sneezing after subcutaneous immunotherapy may indicate impending anaphylaxis and
assessment and emergency measures should be initiated. The other patients also have findings
that need assessment and intervention by the nurse, but do not have evidence of life-
threatening complications.
DIF: Cognitive Level: Analyze (analysis) REF: 216

OBJ: Special Questions: Prioritization; Multiple Patients
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
13. Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What would
the nurse suspect is the cause of this patients skin rash?
a. The donor T cells are attacking the patients skin cells.
b. The patients 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.
ANS: A
The patients history and symptoms indicate that the patient is experiencing graft-versus-host
disease, in which the donated T cells attack the patients tissues. The history and symptoms
are not consistent with rejection or delayed hypersensitivity.
DIF: Cognitive Level: Understand (comprehension) REF: 223-224

14. An adolescent patient seeks care in the emergency department after sharing needles for heroin
injection with a friend who has hepatitis B. To provide immediate protection from infection,
what medication will the nurse administer?
a. Corticosteroids
b. Gamma globulin
c. Hepatitis B vaccine
d. Fresh frozen plasma
ANS: B
The patient should first receive antibodies for hepatitis B from injection of gamma globulin.
The hepatitis B vaccination series should be started to provide active immunity. Fresh frozen
plasma and corticosteroids will not be effective in preventing hepatitis B in the patient.

15. The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by
the patient would indicate a need for further instructions?
a. After a couple of years, it is likely that I will be able to stop taking the
cyclosporine.
b. If I develop an acute rejection episode, I will need to have other types of drugs
given IV.
c. I need to be monitored closely because I have a greater chance of developing
malignant tumors.
d. The drugs are given in combination because they inhibit different ways the
kidney can be rejected.
ANS: A
Cyclosporine, a calcineurin inhibitor, will need to be continued for life. The other patient
statements are accurate and indicate that no further teaching is necessary about those topics.

16. An older adult patient has a prescription for cyclosporine following a kidney transplant.
Which information in the patients health history has the most implications for planning
patient teaching about the medication at this time?
a. The patient restricts salt to treat prehypertension.
b. The patient drinks 3 to 4 quarts of fluids every day.
c. The patient has many concerns about the effects of cyclosporine.
d. The patient has a glass of grapefruit juice every day for breakfast.
ANS: D
Grapefruit juice can increase the toxicity of cyclosporine. The patient should be taught to
avoid grapefruit juice. High fluid intake will not affect cyclosporine levels or renal function.
Cyclosporine may cause hypertension, and the patients many concerns should be addressed,
but these are not potentially life-threatening problems.

17. A patient is admitted to the hospital with acute rejection of a kidney transplant. Which
intervention will the nurse prepare for this patient?
a. Administration of immunosuppressant medications
b. Insertion of an arteriovenous graft for hemodialysis
c. Placement of the patient on the transplant waiting list
d. A blood draw for human leukocyte antigen (HLA) matching
ANS: A
Acute rejection is treated with the administration of additional immunosuppressant drugs such
as corticosteroids. Because acute rejection is potentially reversible, there is no indication that
the patient will require another transplant or hemodialysis. There is no indication for repeat
HLA testing.

18. The charge nurse is assigning rooms for new admissions. Which patient would be the most
appropriate roommate for a patient who has acute rejection of an organ transplant?
a. A patient who has viral pneumonia
b. A patient with second-degree burns
c. A patient who is recovering from an anaphylactic reaction to a bee sting
d. A patient with graft-versus-host disease after a recent bone marrow transplant
ANS: C
Treatment for a patient with acute rejection includes administration of additional
immunosuppressants, and the patient should not be exposed to increased risk for infection as
would occur from patients with viral pneumonia, graft-versus-host disease, and burns. There
is no increased exposure to infection from a patient who had an anaphylactic reaction.
OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
19. A patient who has received allergen testing using the cutaneous scratch method has developed
itching and swelling at the skin site. Which action should the nurse take first?
a. Administer epinephrine.
b. Apply topical hydrocortisone.
c. Monitor the patient for lower extremity edema.
d. Ask the patient about exposure to any new lotions or soaps.
ANS: A
The initial symptoms of anaphylaxis are itching and edema at the site of the exposure.
Hypotension, tachycardia, dilated pupils, and wheezes occur later. Rapid administration of
epinephrine when excessive itching or swelling at the skin site is observed can prevent the
progression to anaphylaxis. Topical hydrocortisone would not deter an anaphylactic reaction.
Exposure to lotions and soaps does not address the immediate concern of a possible
anaphylactic reaction. The nurse should not wait and observe for edema. The nurse should act
immediately in order to prevent progression to anaphylaxis.

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
20. A patient who is anxious and has difficulty breathing seeks treatment after being stung by a
wasp. What is the nurses priority action?
a.Have the patient lie down.
b.Assess the patients airway.
c.Administer high-flow oxygen.
d.Remove the stinger from the site.
ANS: B
The initial action with any patient with difficulty breathing is to assess and maintain the
airway. The other actions also are part of the emergency management protocol for
anaphylaxis, but the priority is airway maintenance.

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
21. Immediately after the nurse administers an intracutaneous injection of an allergen on the
forearm, a patient complains of itching at the site and of weakness and dizziness. What action
should the nurse take first?
a. Remind the patient to remain calm.
b. Administer subcutaneous epinephrine.
c. Apply a tourniquet above the injection site.
d. Rub a local antiinflammatory cream on the site.
ANS: C
Application of a tourniquet will decrease systemic circulation of the allergen and should be
the first reaction. A local antiinflammatory cream may be applied to the site of a cutaneous
test if the itching persists. Epinephrine will be needed if the allergic reaction progresses to
anaphylaxis. The nurse should assist the patient to remain calm, but this is not an adequate
initial nursing action.

22. A clinic patient is experiencing an allergic reaction to an unknown allergen. Which action is
most appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational
nurse (LPN/LVN)?
a. Perform a focused physical assessment.
b. Obtain the health history from the patient.
c. Teach the patient about the various diagnostic studies.
d. Administer skin testing by the cutaneous scratch method.
ANS: D
LPN/LVNs are educated and licensed to administer medications under the supervision of an
RN. RN-level education and the scope of practice include assessment of health history,
focused physical assessment, and patient teaching.

OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
23. The health care provider asks the nurse whether a patients angioedema has responded to
prescribed therapies. Which assessment should the nurse perform?
a. Ask the patient about any clear nasal discharge.
b. Obtain the patients blood pressure and heart rate.
c. Check for swelling of the patients lips and tongue.
d. Assess the patients extremities for wheal and flare lesions.
ANS: C
Angioedema is characterized by swelling of the eyelids, lips, and tongue. Wheal and flare
lesions, clear nasal drainage, and hypotension and tachycardia are characteristic of other
allergic reactions.

24. A nurse has obtained donor tissue typing information about a patient who is waiting for a
kidney transplant. Which results should be reported to the transplant surgeon?
a. Patient is Rh positive and donor is Rh negative
b. Six antigen matches are present in HLA typing
c. Results of patient-donor cross matching are positive
d. Panel of reactive antibodies (PRA) percentage is low
ANS: C
Positive crossmatching is an absolute contraindication to kidney transplantation, since a
hyperacute rejection will occur after the transplant. The other information indicates that the
tissue match between the patient and potential donor is acceptable.

25. A patient who is receiving immunotherapy has just received an allergen injection. Which
assessment finding is most important to communicate to the health care provider?
a. The patients IgG level is increased.
b. The injection site is red and swollen.
c. The patients allergy symptoms have not improved.
d. There is a 2-cm wheal at the site of the allergen injection.
ANS: D
A local reaction larger than quarter size may indicate that a decrease in the allergen dose is
needed. An increase in IgG indicates that the therapy is effective. Redness and swelling at the
site are not unusual. Because immunotherapy usually takes 1 to 2 years to achieve an effect,
an improvement in the patients symptoms is not expected after a few months.

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
OTHER
1. A patient who is receiving an IV antibiotic develops wheezes and dyspnea. In which order
should the nurse implement these prescribed actions? (Put a comma and a space between
each answer choice [A, B, C, D, E]).
a. Discontinue the antibiotic infusion.
b. Give diphenhydramine (Benadryl) IV.
c. Inject epinephrine (Adrenalin) IM or IV.
d. Prepare an infusion of dopamine (Intropin).
e. Start 100% oxygen using a nonrebreather mask.
ANS:
A, E, C, B, D
The nurse should initially discontinue the antibiotic because it is the likely cause of the
allergic reaction. Next, oxygen delivery should be maximized, followed by treatment of
bronchoconstriction with epinephrine administered IM or IV. Diphenhydramine will work
more slowly than epinephrine, but will help prevent progression of the reaction. Because the
patient currently does not have evidence of hypotension, the dopamine infusion can be
prepared last.


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Chapter 14: Altered Immune Responses, and Transplantation

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12. Which patient should the nurse assess first?

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