Immune Responses, and Transplantation

Lewis: Medical-Surgical Nursing, 7
th
Edition

Chapter 14: Genetics, Altered Immune Responses, and Transplantation

MULTIPLE CHOICE

1. A young womans mother has been diagnosed with BRCA gene-associated breast cancer. The patient asks the nurse, Do
you think I should be tested for the gene? Which response by the nurse is most appropriate?
a. You should decide first whether you are willing to have a double mastectomy.
b. It depends on how you will feel if the test is positive for the BRCA gene.
c. There are many things to consider before deciding to have genetic testing.
d. In most cases, breast cancer is not caused by the BRCA gene.

Correct Answer: C
Rationale: Although presymptomatic testing for genetic disorders allows patients to take action (such as mastectomy) to prevent
the development of some genetically caused disorders, patients also need to consider that test results in their medical file may
impact insurance, employability, etc. Telling a patient that a decision about mastectomy should be made before testing implies
that the nurse has made a judgment about what the patient should do if the test is positive. Although the patient may need to think
about her reaction if the test is positive, other issues (e.g., insurance) also should be considered. Although most breast cancers are
not caused by the BRCA gene, the patient with the gene has a markedly increased risk for breast cancer.

Cognitive Level: Application Text Reference: p. 216
Nursing Process: Implementation NCLEX: Physiological Integrity

2. A patient seen in the outpatient clinic has an immune deficiency involving the T-lymphocytes. The nurse should teach the
patient about the need for more frequent screening for
a. malignancy.
b. allergies.
c. autoimmune disorders.
d. antibody deficiency.

Correct Answer: A
Rationale: Cell-mediated immunity is responsible for the recognition and destruction of cancer cells. Allergic reactions,
autoimmune disorders, and antibody deficiencies are mediated primarily by humoral immunity.

Nursing Process: Implementation
NCLEX: Health Promotion and Maintenance

3. In counseling a couple when the man has sickle cell disease, an autosomal-recessive disorder, and the woman has no gene for sickle cell
disease, the nurse uses Punnett squares to show the couple that the probability of them having a child with sickle cell disease is
a. 0%.
b. 25%.
c. 50%.
d. 75%.

Correct Answer: A
Rationale: When one parent has no gene for an autosomal-recessive disorder, the children will not display the characteristics of the disorder,
although the children will be carriers of sickle cell trait.

Cognitive Level: Application Text Reference: pp. 215-216

4. The nurse encourages a new mother to breastfeed her infant, even for a short time, because colostrum will provide the infant with
a. active immunity to many childhood illnesses for several years.
b. passive immunity to all childhood illnesses for several months.
c. passive immunity to diseases to which the mother has immunity.
d. innate immunity to diseases to which the mother is immune.

Correct Answer: C

Rationale: Colostrum provides passive immunity through antibodies from the mother that protects the infant for a few months; however, memory
cells are not retained, so the protection is not permanent. Active immunity requires that the infant manufacture antibodies after exposure to an
antigen. Innate immunity occurs without exposure to an antigen and provides species-specific immunity and nonspecific immunity.

Cognitive Level: Comprehension Text Reference: p. 219

5. A patient is being evaluated for possible atopic dermatitis. The nurse will review the patients laboratory values for the level of
a. IgE.
b. neutrophils.
c. basophils.
d. IgA.

Correct Answer: A
Rationale: Serum IgE causes the symptoms of allergic reactions and is elevated in type 1 hypersensitivity disorders. 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.

Cognitive Level: Application Text Reference: pp. 220, 225
Nursing Process: Assessment NCLEX: Physiological Integrity

6. An older patient at the clinic for an annual examination tells the nurse, I dont understand why I need to have so many cancer screening
tests now. I feel just fine! The nurse will plan to teach the patient about the
a. decrease in antibody production associated with aging.
b. impact of poor nutrition on immune function in older people.
c. consequences of aging for cell-mediated immunity.
d. incidence of cancer-stimulating infections in older individuals.

Correct Answer: C
Rationale: The primary impact of aging on immune function is on the activity of T cells, which are responsible for tumor immunity. Antibody
function is not impacted as much by aging and does not protect against malignancy. Poor nutrition does 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.

Nursing Process: Planning NCLEX: Physiological Integrity

7. To prevent anaphylaxis after a patient has received allergen testing using the cutaneous scratch method, the nurse should initially monitor
the patients
a. blood pressure and pulse.
b. pupil size and reaction to light.
c. arm at the site of the skin testing.
d. bilateral lung sounds.

Correct Answer: C
Rationale: 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.


8. A patient develops a severe angioedema involving the face, hands, and feet, with burning and stinging of the lesions. A significant risk factor
for allergies that the nurse questions the patient about is
a. family history of allergic reactions.
b. living in an underdeveloped country.
c. a recent upper respiratory infection.
d. any exposure to fungal infections.

Correct Answer: A
Rationale: A genetic predisposition to develop allergic reactions exists, although the specific allergy may be different in individual family
members. Living in an underdeveloped country, upper respiratory infections, and fungal infections are not risk factors for allergic reactions.

Cognitive Level: Application Text Reference: pp. 225, 228-229

9. A patient with a severe allergic reaction receives epinephrine 1:10,000 0.5 ml IV. The next action that the nurse should take is to
a. start oxygen at 100% using a non-rebreather mask.
b. administer diphenhydramine (Benadryl) IV.
c. give a dose of cimetidine (Tagamet).
d. prepare an infusion of dopamine (Intropin).

Correct Answer: A
Rationale: After administration of epinephrine, the nurse should maximize oxygenation by administration of high-flow oxygen. The other
actions are also appropriate, but oxygenation is the priority.


10. After being bitten by an unknown insect, a patient allergic to wasp stings is brought to a clinic by a co-worker. Upon arrival the patient is
anxious and having difficulty breathing. The first action by the nurse is to
a. administer high-flow oxygen.
b. maintain the patients airway.
c. remove the stinger from the site.
d. have the patient lie down.

Correct Answer: B
Rationale: The initial action with any patient with difficulty breathing is to assess and maintain the airway. The other actions are also part of the
emergency management protocol for anaphylaxis, but the priority is airway maintenance.


11. The nurse discusses the prevention and management of allergic reactions with a beekeeper who has developed a hypersensitivity to bee
stings. The nurse identifies a need for additional teaching when the patient states,
a. I am going to need job retraining so that I can work in a different occupation.
b. I should wear a Medic Alert bracelet indicating my allergy to insect stings.
c. I will learn to administer epinephrine so that I will be prepared if I am stung again.
d. I can take maintenance doses of corticosteroids to prevent reactions to further stings.

Correct Answer: D
Rationale: Corticosteroids have many systemic effects and are used chronically only when there is no alternative. The other statements by the
patient are correct and indicate that teaching about these topics has been understood.

Cognitive Level: Application Text Reference: pp. 231, 239
Nursing Process: Evaluation NCLEX: Physiological Integrity

12. Immediately after the nurse administers an intracutaneous injection of an allergen on a patients forearm, the patient complains of itching at
the site and of weakness and dizziness. The nurse should first
a. apply a tourniquet above the injection site.
b. rub a local antiinflammatory cream on the site.
c. remind the patient to remain calm.
d. administer subcutaneous epinephrine.

Correct Answer: A
Rationale: Application of a tourniquet will decrease systemic circulation of the allergen and should be the first reaction. A local anti-
inflammatory 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 patient should be reassured, but this is not an adequate initial nursing action.


13. A patient is treated at a clinic with an intramuscular (IM) injection of penicillin for a streptococcal throat infection. The patients history
reveals a prior penicillin injection with no allergic response. When the penicillin injection is administered, the nurse should tell the patient,
a. You will need to wait in the clinic area for 20 minutes after the injection.

b. Since you have taken penicillin before, there should be no problem this time.
c. If you have a penicillin allergy, you will react immediately to the injection.
d. Call if you develop any fever or skin rash in the next 24 to 48 hours.

Correct Answer: A
Rationale: Allergic reactions usually occur within minutes after injection of an allergen, and the patient will be monitored for about 20 minutes
after the penicillin is given. Once a patient has been initially exposed to an allergen such as penicillin, an allergic reaction may occur with any
subsequent exposure. Although allergic reactions may occur immediately, they can occur several hours after exposure to the allergen. A fever or
skin rash occurring in 24 to 48 hours is not typical of a penicillin reaction.


14. The nurse obtains all this information about a patient who has been receiving immunotherapy for several months and is waiting in the clinic
after receiving the allergen injection. Which information should the nurse communicate to the health care provider?
a. The patients IgG level is increased.
b. The injection site is red and swollen.
c. There is a 3-cm wheal at the site of the allergen injection.
d. The patients allergy symptoms have not improved.

Correct Answer: C
Rationale: 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.


15. A patient who receives weekly allergy shots at a clinic missed the previous appointment. When the patient comes for the next injection,
the nurse should
a. administer the usual dosage of the allergen.
b. re-evaluate the patients sensitivity to the allergen with a skin test.
c. consult with the health care provider about giving a lower dose for this injection.
d. schedule an additional dose that week.

Correct Answer: C
Rationale: 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.


16. A patient who is employed as a laboratory technician is scheduled for surgery. While obtaining a health history from the patient, the nurse
learns that the patient has a history of allergic rhinitis, asthma, and multiple food allergies. It is important that the nurse
a. encourage the patient to carry an epinephrine kit in case a type IV allergic reaction to latex develops.
b. document the patients allergy history and be alert for any clinical manifestations of a type I latex allergy.
c. advise the patient to use oil-based hand creams to decrease contact with natural proteins in latex gloves.
d. recommend that the patient use vinyl gloves instead of latex gloves in preventing blood-borne pathogen
contact.

Correct Answer: B
Rationale: The patients 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
in unlikely.

Cognitive Level: Analysis Text Reference: p. 232

17. A patient diagnosed with systemic lupus erythematosus (SLE) is scheduled for plasmapheresis. The nurse plans to teach the patient that
plasmapheresis will
a. decrease the damage to organs caused by attacking T-lymphocytes.

b. remove antibody-antigen complexes from circulation.
c. prevent foreign antibodies from damaging various body tissues.
d. eliminate eosinophils and basophils from blood.

Correct Answer: B
Rationale: Plasmapheresis is used in SLE to remove antibodies, antibody-antigen complexes, and complement from blood. T-lymphocytes,
foreign antibodies, eosinophils, and basophils do not contribute to the tissue damage in SLE.

Cognitive Level: Comprehension Text Reference: pp. 234-235

18. The nurse will monitor a patient who is undergoing plasmapheresis for
a. numbness and tingling.
b. high blood pressure.
c. shortness of breath.
d. transfusion reactions.

Correct Answer: A
Rationale: 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.


19. While the nurse is obtaining an assessment and health history from a patient, which statement by the patient will alert the nurse to a possible
immunodeficiency disorder?
a. I had my spleen removed many years ago after a car accident.
b. I usually eat eggs or meat for at least 2 meals every day.
c. I enjoy walking several times a week with friends.
d. I had a chest x-ray 6 months ago when I had pneumonia.

Correct Answer: A
Rationale: Splenectomy increases the risk for septicemia from bacterial infections. The patients protein intake is good and should improve
immune function. Walking with friends may reduce stress and improve immune function. A chest radiography does not have enough radiation to
suppress immune function.


20. A patient who received a bone marrow transplant for treatment of leukemia develops a skin rash 10 days after the transplant. The nurse
recognizes this reaction as an indication that the
a. donor T cells are attacking the patients skin cells.
b. patients circulating antibodies are rejecting the donor bone marrow.
c. patient is experiencing a delayed hypersensitivity reaction.
d. patient will need treatment to prevent graft-versus-host disease.

Correct Answer: A
Rationale: 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. Graft-versus-host disease
cannot be prevented once it has occurred.


21. A patient seeks medical care after sharing needles for heroin injection with a friend who has hepatitis B. To provide immediate protection
from infection, the nurse expects to administer
a. hepatitis B vaccine.
b. fresh frozen plasma.
c. corticosteroids.
d. gamma globulin.

Correct Answer: D

Rationale: 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.


22. When the nurse is admitting a patient who has acute rejection of an organ transplant, which of these already-admitted patients will be the
most appropriate roommate?
a. A patient who has viral pneumonia
b. A patient with graft-versus-host disease after a recent bone marrow transplant
c. A patient who is recovering from an anaphylactic reaction to a bee sting
d. A patient with second degree burns

Correct Answer: C
Rationale: 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 with anaphylaxis.

Nursing Process: Planning
NCLEX: Safe and Effective Care Environment

23. After teaching a patient on immunosuppressant therapy after a kidney transplant about the posttransplant drug regimen, the nurse determines
that additional teaching is needed when the patient says,
a. I need to be monitored closely because I have a greater chance of developing malignant tumors.
b. If I develop an acute rejection episode, I will need to have other types of drugs given IV.
c. After a couple of years, it is likely that I will be able to stop taking the calcineurin inhibitor.
d. The drugs are given in combination because they act differently to inhibit cytokine production and
lymphocyte activity.

Correct Answer: C
Rationale: The 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.


24. A patient has a new prescription for cyclosporine after having 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 drinks 3 to 4 quarts of fluids every day.
b. The patient restricts salt to treat prehypertension.
c. The patient likes to have orange or grapefruit juice for breakfast.
d. The patient has many concerns about the effects of cyclosporine.

Correct Answer: C
Rationale: Grapefruit juice can increase the cyclosporine to toxic levels; the patient should be taught to avoid grapefruit juice. High fluid intake
will not impact 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.


25. A pregnant patient with a family history of cystic fibrosis (CF) asks for information about genetic testing. The most appropriate action by the
nurse is to
a. refer the patient to a qualified genetic counselor.
b. remind the patient that genetic testing has many social implications.
c. tell the patient that cystic fibrosis is an autosomal-recessive disorder.
d. ask the patient why genetic testing is important to her.

Correct Answer: A

Rationale: A genetic counselor is best qualified to address the multiple issues involved in genetic testing for a patient who is considering having
children. Although genetic testing does have social implications, a pregnant patient will be better served by a genetic counselor who will have
more expertise in this area. CF is an autosomal-recessive disorder, but the patient might not understand the implications of this statement. Asking
why the patient feels genetic testing is important may imply to the patient that the nurse is questioning her value system regarding issues such as
abortion.

Nursing Process: Implementation NCLEX: Psychosocial Integrity

26. When caring for a clinic patient who is experiencing an allergic reaction to an unknown allergen, which nursing activity is most appropriate
for the RN to delegate to an LPN/LVN?
a. Obtain the health history from the patient.
b. Perform a focused physical assessment.
c. Administer skin testing by the cutaneous scratch method.
d. Teach the patient about the various diagnostic studies.

Correct Answer: C
Rationale: LPN/LVNs are educated and licensed to administer medications under the supervision of an RN. RN-level education and the scope of
practice includes assessment of health history, focused physical assessment, and patient teaching.

NCLEX: Safe and Effective Care Environment

27. A man with mild hemophilia, a sex-linked recessive disorder, asks the nurse, Will my children be hemophiliacs? Which response by the
nurse is appropriate?
a. Only your male children are at risk for hemophilia.
b. Your female children will be carriers for hemophilia.
c. All of your children will be at risk for hemophilia.
d. Hemophilia is a multifactorial inherited condition.

Correct Answer: B
Rationale: Because hemophilia is caused by a mutation of the X-chromosome, all female children of a man with hemophilia are carriers of the
disorder and can transmit the mutated gene to their offspring. Sons of a man with hemophilia will not have the disorder. Hemophilia is caused by
a genetic mutation and is not a multifactorial inherited condition.

Cognitive Level: Application Text Reference: pp. 215-216

28. A patient seen at the clinic with atopic dermatitis has a history of multiple allergies and several previous anaphylactic reactions. Which type
of testing for allergens will the nurse anticipate for this patient?
a. Radioallergosorbent test (RAST)
b. Cutaneous scratch test
c. Intracutaneous skin test
d. Serum IgE-level test

Correct Answer: A
Rationale: RAST is an in vitro test for hypersensitivity to specific allergens that is used when patients are likely to have anaphylactic reactions to
other forms of skin testing. Cutaneous scratch testing or intracutaneous testing is more likely to cause anaphylaxis. Serum IgE level is elevated in
atopic reactions but is not diagnostic for specific allergens.

NCLEX: Health Promotion and Maintenance
29. A patient is admitted to the hospital with acute rejection of a kidney transplant. The nurse will anticipate
a. placement of the patient on the transplant waiting list.
b. insertion of an arteriovenous graft for hemodialysis.
c. administration of immunosuppressant medications.
d. drawing blood for HLA and ABO compatibility matching.

Correct Answer: C
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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