A nurse is preparing to administer plasmapheresis to a client diagnosed with systemic lupus erythematosus (SLE). Which of the following assessments should the nurse prioritize most before beginning the procedure?

Choice A rationale

The fundamental principle of preventing graft rejection involves the pharmacological suppression of the recipient immune system. Immunosuppressive medications, such as corticosteroids, calcineurin inhibitors like tacrolimus, and antimetabolites like mycophenolate mofetil, work by inhibiting T-cell activation and proliferation. By reducing the immune response against the non-self HLA antigens of the donor kidney, these drugs prevent the body from attacking the new organ. This lifelong therapy is essential for maintaining long-term graft survival.

Choice B rationale

Chronic rejection is a slow, progressive immunological and non-immunological process resulting in irreversible fibrosis and scarring of the renal parenchyma. Unlike acute rejection, which often responds to increased doses of immunosuppressants or pulse steroids, chronic rejection is generally refractory to augmented immunosuppression. Management focuses on controlling blood pressure, managing lipids, and optimizing current medication levels to slow the decline of renal function rather than reversing the underlying chronic damage already sustained by the organ.

Choice C rationale

Comprehensive postoperative education is a critical component of transplant success and patient safety. Patients must understand the physiological signs of rejection, such as fever, decreased urine output, and graft tenderness, to seek medical intervention immediately. Lack of education increases the risk of medication non-adherence and delayed recognition of complications. Understanding the rejection process empowers patients to participate in their care, which significantly correlates with improved long-term clinical outcomes and graft longevity.

Choice D rationale

Clinical presentations vary significantly based on the timing and mechanism of rejection. Hyperacute rejection occurs within minutes due to preformed antibodies, leading to immediate thrombosis. Acute rejection, occurring days to months later, may present with systemic symptoms like fever and elevated creatinine levels. Chronic rejection is often asymptomatic initially, manifesting only as a gradual decline in the glomerular filtration rate over years. Therefore, nurses must teach that symptoms are not uniform across all types of rejection.

Choice E rationale

Hyperacute rejection is a type II hypersensitivity reaction caused by pre-existing antibodies against the donor's ABO blood group or HLA antigens. This results in immediate complement activation, massive intravascular coagulation, and hemorrhagic necrosis of the graft. Because this process is irreversible and occurs almost instantly upon anastomosis of the vessels, the only clinical intervention is the immediate surgical removal of the transplanted kidney to prevent systemic inflammatory response syndrome and further life-threatening complications.

Choice F rationale

Dialysis is not a universal requirement for monitoring or managing all rejection episodes. While dialysis may be necessary if a rejection episode leads to severe acute kidney injury or complete graft failure, many acute rejection episodes are successfully managed with high-dose intravenous medications without the need for renal replacement therapy. Monitoring graft function primarily involves serial measurements of serum creatinine, blood urea nitrogen, and urine output, alongside renal biopsies, rather than the routine use of dialysis.

Choice A rationale

Glucocorticoids are essential for maintaining vascular tone and metabolic homeostasis. In Addison's disease, the adrenal cortex is unable to produce sufficient cortisol. If exogenous steroid replacement is stopped abruptly, the body cannot mount a physiological response to even minor stressors. This leads to a rapid decline in blood pressure and vascular collapse known as an adrenal crisis. Tapering is required to allow any residual adrenal function to adapt or to maintain systemic stability.

Choice B rationale

Extreme emotional stress triggers the hypothalamic pituitary adrenal axis to demand increased cortisol production. In a client with Addison's disease, the damaged adrenal glands cannot meet this increased demand for glucocorticoids. This deficiency during periods of high psychological or physiological tension leads to acute adrenal insufficiency. Patients are often taught to increase their medication dosage during these times, known as stress dosing, to prevent the onset of life threatening hypotension and electrolyte imbalances.

Choice C rationale

Surgery and severe illness represent profound physiological stressors that require a massive increase in systemic cortisol levels to maintain hemodynamic stability and glucose levels. For a patient with primary adrenal insufficiency, these events quickly exhaust the baseline levels of replaced hormones. Without supplemental intravenous hydrocortisone during the perioperative or acute illness phase, the patient will experience a crisis characterized by profound dehydration, hyperkalemia, and shock due to the lack of mineralocorticoid and glucocorticoid activity.

Choice D rationale

Regular, moderate exercise is generally encouraged for patients with Addison's disease to maintain cardiovascular health and bone density. While extreme physical overexertion could theoretically act as a stressor, standard exercise during consistent medication therapy is not a primary trigger for adrenal crisis. Patients should be monitored for heat exhaustion and salt loss during heavy sweating, but the act of exercising itself is not an indication of imminent adrenal failure if the patient is adequately replaced.

Choice E rationale

Diet does not directly trigger an adrenal crisis, although patients with Addison's disease often require a high sodium intake to compensate for the lack of aldosterone. A high sugar diet may lead to other health complications like obesity or dental caries, but it does not cause the acute hormonal collapse seen in Addison's. Adrenal crisis is primarily a failure of the stress response system rather than a reaction to specific macronutrient ratios or dietary sugar concentrations.