Certified Clinical Transplant Nurse (CCTN) — Questions and Answers

Question 1: A parasite that most frequently spreads from animals to people through contact with infected animal feces. More frequent in the heart since it occurs in the cardiac muscle. Van imitates heart rejection.

Corticosteroids
Lyme Disease
Toxoplasmosis (Correct answer)
Cytomegalovirus

Correct answer: Toxoplasmosis

Toxoplasmosis, caused by the parasite *Toxoplasma gondii*, is often transmitted through contact with infected animal feces. In immunocompromised individuals, such as transplant recipients, it can cause myocarditis (inflammation of the heart muscle). The symptoms of toxoplasmosis-induced myocarditis can mimic those of heart rejection, making accurate diagnosis challenging but critical for appropriate treatment.

Question 2: A renal transplant recipient who is 3 years post-transplant presents with gradually rising creatinine, proteinuria, and hypertension without episodes of acute rejection. Biopsy shows interstitial fibrosis and tubular atrophy. This pattern is MOST consistent with:

Chronic allograft nephropathy (interstitial fibrosis/tubular atrophy) (Correct answer)
Recurrent primary disease
BK virus nephropathy
Acute antibody-mediated rejection

Correct answer: Chronic allograft nephropathy (interstitial fibrosis/tubular atrophy)

Interstitial fibrosis and tubular atrophy (IF/TA) is the histologic hallmark of chronic allograft nephropathy, the leading cause of late graft loss.

Question 3: A lung transplant recipient develops bronchiolitis obliterans syndrome (BOS). How does BOS increase infection risk?

BOS causes T-cell exhaustion, increasing viral reactivation risk
BOS triggers autoimmune destruction of bronchial-associated lymphoid tissue
Impaired mucociliary clearance and airway structural changes create a favorable environment for bacterial colonization (Correct answer)
BOS directly suppresses neutrophil function and phagocytosis

Correct answer: Impaired mucociliary clearance and airway structural changes create a favorable environment for bacterial colonization

BOS damages the airway epithelium and mucociliary apparatus, impairing pathogen clearance and promoting chronic bacterial colonization with organisms like Pseudomonas aeruginosa.

Question 4: Which infection control precaution is most critical for transplant nurses to implement when caring for a transplant recipient with suspected Clostridioides difficile (C. diff) infection?

Standard precautions alone are sufficient for C. diff management
Airborne precautions with N95 respirator and negative-pressure room
Droplet precautions with surgical mask and eye protection
Contact precautions with gown and gloves, using soap and water for hand hygiene (not alcohol gel) (Correct answer)

Correct answer: Contact precautions with gown and gloves, using soap and water for hand hygiene (not alcohol gel)

C. difficile spores are not killed by alcohol-based hand sanitizers, so soap and water handwashing plus contact precautions (gown and gloves) are essential to prevent transmission.

Question 5: Which organism causes PCP (Pneumocystis pneumonia) in immunocompromised transplant patients?

Cryptococcus neoformans
Pneumocystis jirovecii (Correct answer)
Aspergillus fumigatus
Candida albicans

Correct answer: Pneumocystis jirovecii

Pneumocystis jirovecii (formerly P. carinii) causes PCP, a serious fungal pneumonia requiring TMP-SMX prophylaxis post-transplant.

Question 6: A kidney transplant recipient presents with a creatinine that has doubled over 5 days with no fever, oliguria, or graft tenderness, and a therapeutic tacrolimus level. What is the MOST appropriate next diagnostic step?

Renal transplant biopsy to differentiate rejection from other causes (Correct answer)
Initiate dialysis immediately
Increase tacrolimus dose to higher target
Empiric pulse-dose steroids for presumed rejection

Correct answer: Renal transplant biopsy to differentiate rejection from other causes

A transplant biopsy is the gold standard for diagnosing the cause of graft dysfunction and distinguishing acute rejection from CNI toxicity, BK nephropathy, or recurrent disease.

Question 7: Which of the following is a classic sign of acute rejection in a kidney transplant recipient?

Oliguria, rising creatinine, and graft tenderness (Correct answer)
Fever and skin rash only
Polyuria and hypotension
Hypoglycemia and jaundice

Correct answer: Oliguria, rising creatinine, and graft tenderness

Acute kidney rejection typically presents with decreased urine output, rising serum creatinine, and tenderness over the transplanted kidney.

Question 8: Which term describes the production of donor-specific antibodies after transplantation that were not present before the procedure?

De novo donor-specific antibody formation (Correct answer)
Allorecognition
Primary sensitization
Passive immunity

Correct answer: De novo donor-specific antibody formation

De novo donor-specific antibody (DSA) formation refers to new antibodies produced after transplant targeting donor HLA antigens, associated with chronic antibody-mediated rejection.

Question 9: Which clinical finding differentiates hepatic artery thrombosis (HAT) from biliary stricture in a liver transplant recipient?

HAT causes dramatically elevated transaminases and can cause fulminant graft failure; biliary strictures cause cholestatic LFT pattern (Correct answer)
HAT presents only with fever and bacteremia
Biliary stricture causes graft failure while HAT causes cholestasis
Both present identically; only biopsy distinguishes them

Correct answer: HAT causes dramatically elevated transaminases and can cause fulminant graft failure; biliary strictures cause cholestatic LFT pattern

HAT presents acutely with ischemic hepatocyte injury (high AST/ALT) and can precipitate graft necrosis, while biliary strictures cause a more insidious cholestatic pattern with elevated bilirubin and alkaline phosphatase.

Question 10: What is the primary risk associated with a CMV-negative recipient receiving an organ from a CMV-positive donor?

Increased tacrolimus toxicity
Graft-versus-host disease
Hyperacute rejection
Primary CMV infection leading to CMV disease (Correct answer)

Correct answer: Primary CMV infection leading to CMV disease

A D+/R- mismatch places the recipient at highest risk for primary CMV disease because they lack prior immunity.

Question 11: A transplant nurse is educating a recipient about food safety. Which food should be specifically avoided to prevent Listeria monocytogenes infection?

Well-cooked poultry and pasteurized dairy products
Canned vegetables and commercially bottled juices
Unpasteurized soft cheeses and ready-to-eat deli meats (Correct answer)
Fresh fruits that are washed before consumption

Correct answer: Unpasteurized soft cheeses and ready-to-eat deli meats

Listeria thrives in refrigerated, ready-to-eat foods such as deli meats and soft cheeses made from unpasteurized milk, and causes severe invasive disease in immunocompromised transplant recipients.

Question 12: Which blood group compatibility rule is universally applied in solid organ transplantation?

Donor and recipient must share the same Rh factor
ABO blood group compatibility between donor and recipient is required (Correct answer)
Blood type is irrelevant in deceased donor transplants
Only HLA matching is required, not ABO

Correct answer: ABO blood group compatibility between donor and recipient is required

ABO blood group compatibility is required in solid organ transplantation because ABO antigens are expressed on vascular endothelium and can trigger hyperacute rejection.

Question 13: Which statement about returning to work after kidney transplantation is most accurate?

Recipients should return to work within 2 weeks to maintain normalcy
Most recipients can return to work within 3–6 months if recovery is uncomplicated, depending on job type and graft function (Correct answer)
All transplant recipients are permanently disabled and cannot work
Return to work is not recommended due to infection risk in workplace environments

Correct answer: Most recipients can return to work within 3–6 months if recovery is uncomplicated, depending on job type and graft function

Most kidney transplant recipients with uncomplicated recovery can return to work within 3–6 months, though timeline varies by physical job demands and individual recovery.

Question 14: The majority of patients will have an intradermal skin examination for TB. However, some people could be anergic because of their severe conditions. In such circumstances, the patient will get control. The two kin test controls that are most often utilized are:

Candida and mumps (Correct answer)
Measles and influenza
Mumps and BCG
Bacillus Calmette-Guerin (BCG) and human T-lymphotropic virus-1 (HTLV-1)

Correct answer: Candida and mumps

In patients suspected of anergy (inability to mount an immune response), control skin tests are administered to confirm their immune status. Candida and mumps antigens are commonly used as controls because most individuals have been exposed to these pathogens and would typically show a positive skin reaction if their immune system is functional. A negative reaction to these controls indicates anergy.

Question 15: Which statement best describes tolerance in transplantation?

The donor kidney functions normally without HLA matching
The recipient's immune system is permanently suppressed
The graft is rejected slowly over years
The recipient accepts the graft without ongoing immunosuppression (Correct answer)

Correct answer: The recipient accepts the graft without ongoing immunosuppression

Operational tolerance means the recipient's immune system accepts the graft as self without requiring long-term immunosuppressive therapy.

Question 16: Which of the following is a contraindication to living kidney donation?

Uncontrolled diabetes mellitus (Correct answer)
Controlled well-managed hypertension with no end-organ damage in a donor over 18
Single episode of resolved UTI
BMI of 27

Correct answer: Uncontrolled diabetes mellitus

Uncontrolled diabetes mellitus is a contraindication to living donation because it significantly increases the donor's risk of future kidney failure.

Question 17: Cold ischemia time refers to which period in organ transplantation?

Time from brain death declaration to procurement
Time from cross-clamp to organ reperfusion in the recipient
Time the organ spends in warm conditions before preservation
Time between organ procurement and transplantation into the recipient (Correct answer)

Correct answer: Time between organ procurement and transplantation into the recipient

Cold ischemia time is the period from organ procurement and cooling to transplantation and reperfusion, during which the organ is preserved in cold storage solution.

Question 18: BK polyomavirus nephropathy is a significant concern primarily in which type of solid organ transplant recipient?

Liver transplant recipients
Lung transplant recipients
Heart transplant recipients
Kidney transplant recipients (Correct answer)

Correct answer: Kidney transplant recipients

BK virus predominantly replicates in the urothelium and tubular epithelium, making kidney transplant recipients the population most at risk for BK nephropathy and graft loss.

Question 19: A pancreas transplant recipient develops hyperglycemia 1 week post-transplant. What is the most urgent complication to rule out?

Dietary non-compliance
Tacrolimus-induced diabetes
Steroid-induced hyperglycemia
Pancreatic graft thrombosis (Correct answer)

Correct answer: Pancreatic graft thrombosis

Pancreatic graft thrombosis is the most common cause of early pancreas graft loss and presents with sudden hyperglycemia — vascular imaging is urgently required.

Question 20: A kidney transplant recipient is found to have rising BK viremia on routine surveillance. What is the most appropriate initial intervention?

Initiate high-dose intravenous acyclovir therapy
Reduce immunosuppression, particularly the antimetabolite dose (Correct answer)
Add fluoroquinolone antibiotics to suppress viral replication
Immediately begin cidofovir infusions

Correct answer: Reduce immunosuppression, particularly the antimetabolite dose

The primary treatment for BK viremia in kidney transplant recipients is reduction of immunosuppression, which allows the host immune system to control viral replication, though this must be balanced against rejection risk.

Question 21: In organ procurement, the term 'cold ischemia time' refers to:

Time from donor brain death declaration to incision
Duration the organ spends in the operating room
Time from organ perfusion with cold preservation solution to revascularization in the recipient (Correct answer)
Time from recipient incision to graft reperfusion

Correct answer: Time from organ perfusion with cold preservation solution to revascularization in the recipient

Cold ischemia time begins when the organ is flushed with cold preservation solution and ends when blood flow is restored to the organ in the recipient.

Question 22: C4d deposition on peritubular capillaries is a hallmark finding in which type of renal transplant rejection?

Hyperacute rejection
Chronic cellular rejection
Acute cellular rejection
Antibody-mediated rejection (Correct answer)

Correct answer: Antibody-mediated rejection

C4d deposition on peritubular capillaries is a pathologic marker of antibody-mediated rejection, indicating complement activation by donor-specific antibodies.

Question 23: Which organization manages the national deceased donor organ allocation system in the United States?

Centers for Medicare & Medicaid Services (CMS)
Joint Commission on Accreditation
United Network for Organ Sharing (UNOS) (Correct answer)
American Society of Transplantation (AST)

Correct answer: United Network for Organ Sharing (UNOS)

UNOS manages the national Organ Procurement and Transplantation Network (OPTN) and oversees policies for organ allocation to ensure equitable distribution.

Question 24: Many facilities use enzyme immunoassay for HIV testing. Which of the following techniques confirms ambiguous or positive results?

Western Blot (Correct answer)
Complement dependent cytotoxic assay
Enzyme linked immunosorbent assay (ELISA)
Flow cytometry

Correct answer: Western Blot

The enzyme immunoassay (EIA or ELISA) is a screening test for HIV. If the EIA yields a positive or ambiguous result, a more specific and confirmatory test is required to definitively diagnose HIV infection. The Western Blot is considered the gold standard confirmatory test, as it detects specific HIV antibodies with high accuracy.

Question 25: A liver transplant patient is started on sirolimus. Which side effect should the nurse educate the patient about?

Uveitis
Gingival hyperplasia
Impaired wound healing and hyperlipidemia (Correct answer)
Peripheral neuropathy

Correct answer: Impaired wound healing and hyperlipidemia

Sirolimus commonly causes impaired wound healing and hyperlipidemia, and is often avoided in the early post-transplant period for these reasons.

Question 26: Which laboratory value is most specific for monitoring liver graft function in the immediate post-transplant period?

Prothrombin time/INR (Correct answer)
Serum creatinine
White blood cell count
Serum sodium

Correct answer: Prothrombin time/INR

The liver synthesizes clotting factors, so PT/INR reflects liver synthetic function and is a sensitive early marker of graft performance.

Question 27: Which cardiovascular complication is the leading cause of death in long-term kidney transplant recipients?

Aortic aneurysm
Cardiovascular disease (CAD, MI, stroke) (Correct answer)
Pulmonary embolism
Arrhythmia from tacrolimus

Correct answer: Cardiovascular disease (CAD, MI, stroke)

Cardiovascular disease is the leading cause of death in long-term kidney transplant recipients, driven by traditional risk factors amplified by CNIs, steroids, and chronic kidney disease.

Question 28: Which prophylactic medication is routinely prescribed to prevent Pneumocystis jirovecii pneumonia (PCP) in solid organ transplant recipients?

Fluconazole
Valganciclovir
Trimethoprim-sulfamethoxazole (TMP-SMX) (Correct answer)
Dapsone monotherapy

Correct answer: Trimethoprim-sulfamethoxazole (TMP-SMX)

TMP-SMX (Bactrim) is the first-line prophylactic agent for PCP in immunocompromised transplant patients due to its proven efficacy and broad coverage.

Question 29: A living-donor kidney transplant is being planned. Which statement BEST describes the nurse's role in donor evaluation and advocacy?

The nurse focuses solely on the recipient's well-being and clinical needs
The nurse coordinates surgery scheduling as the primary role
The nurse determines donor eligibility based on creatinine alone
The nurse serves as an independent donor advocate, ensuring the donor's consent is fully informed, voluntary, and free of coercion (Correct answer)

Correct answer: The nurse serves as an independent donor advocate, ensuring the donor's consent is fully informed, voluntary, and free of coercion

The transplant nurse and the independent donor advocate (IDA) role ensure that living donors are fully informed of all risks and that donation is voluntary and uncoerced, protecting donor autonomy.

Question 30: What is the most common reason for graft loss in long-term kidney transplant recipients related to patient behavior?

Excessive exercise damaging the graft
Failure to attend annual follow-up appointments
Dietary non-compliance causing metabolic syndrome
Non-adherence to immunosuppressive medications (Correct answer)

Correct answer: Non-adherence to immunosuppressive medications

Non-adherence to immunosuppressive medications is the leading preventable cause of late graft loss, often resulting in chronic rejection.

Question 31: What is the significance of Panel Reactive Antibody (PRA) percentage in transplant candidates?

It measures liver enzyme levels
It indicates the percentage of donor pool against which the patient has antibodies (Correct answer)
It measures kidney function
It determines blood type compatibility

Correct answer: It indicates the percentage of donor pool against which the patient has antibodies

A high PRA means the recipient has antibodies against a large portion of potential donors, making compatible matching more difficult.

Question 32: What is the rationale for using triple immunosuppression therapy in most solid organ transplant protocols?

To ensure at least one drug is effective if one fails
To reduce cost by using lower doses of each drug
To comply with UNOS regulations
To block multiple pathways of immune activation while minimizing individual drug toxicity (Correct answer)

Correct answer: To block multiple pathways of immune activation while minimizing individual drug toxicity

Triple therapy targets different steps in the immune activation pathway, allowing lower doses of each agent and reducing toxicity while maintaining effective rejection prevention.

Question 33: During the first month post-transplant, which category of infections predominates and reflects the patient's pre-transplant health status and surgical complications?

Community-acquired respiratory infections from environmental exposure
Reactivation of latent viral infections like EBV and VZV
Opportunistic infections from immunosuppression such as CMV and PCP
Donor-derived and recipient pre-existing infections, plus surgical-site and nosocomial infections (Correct answer)

Correct answer: Donor-derived and recipient pre-existing infections, plus surgical-site and nosocomial infections

In the first month post-transplant, infections are similar to those in any post-surgical patient and reflect pre-existing conditions, donor-derived pathogens, and hospital-acquired organisms rather than immunosuppression-driven opportunists.

Question 34: The immunosuppression protocol known as induction therapy in transplantation refers to:

Long-term low-dose steroids used to prevent rejection
Prophylactic antibiotics given before surgery
Intensive immunosuppression given perioperatively to reduce early rejection risk (Correct answer)
Withdrawal of immunosuppression to test for tolerance

Correct answer: Intensive immunosuppression given perioperatively to reduce early rejection risk

Induction therapy uses potent immunosuppressive agents perioperatively to reduce the immune response when the allograft is most vulnerable to rejection.

Question 35: BK virus nephropathy in renal transplant recipients is managed primarily by which intervention?

Increasing immunosuppression to control viral replication
Reducing immunosuppression to allow immune control of the virus (Correct answer)
Administering antiviral therapy with acyclovir
Performing emergent nephrectomy of the graft

Correct answer: Reducing immunosuppression to allow immune control of the virus

BK nephropathy is managed by reducing immunosuppression to allow the recipient's immune system to control BK virus replication and limit nephropathy progression.

Question 36: Prednisone is used in transplant regimens primarily for which mechanism?

Broad anti-inflammatory and immunosuppressive effects via glucocorticoid receptor activation (Correct answer)
Selective T-cell depletion
Blocking B-cell antibody production
Inhibition of IL-2 production specifically

Correct answer: Broad anti-inflammatory and immunosuppressive effects via glucocorticoid receptor activation

Prednisone acts through glucocorticoid receptors to broadly suppress inflammation and immune activation, making it useful as maintenance and anti-rejection therapy.

Question 37: A transplant nurse notes a tacrolimus trough level of 22 ng/mL in a 3-month post-kidney-transplant patient. What is the most appropriate action?

Notify the provider because the level is supratherapeutic (Correct answer)
Document and continue current regimen
Administer a supplemental dose immediately
Increase the dose because levels should be higher at 3 months

Correct answer: Notify the provider because the level is supratherapeutic

At 3 months post-transplant, tacrolimus trough targets are typically 8–12 ng/mL; a level of 22 ng/mL is supratherapeutic and requires physician notification.

Question 38: In a CMV donor-positive/recipient-negative (D+/R-) transplant scenario, what is the recommended management strategy?

Pre-emptive therapy based on weekly CMV PCR monitoring only
No prophylaxis needed since the recipient has no prior exposure
Acyclovir prophylaxis for the first 30 days
Universal prophylaxis with valganciclovir for 3–6 months (Correct answer)

Correct answer: Universal prophylaxis with valganciclovir for 3–6 months

D+/R- is the highest-risk CMV serostatus combination, requiring universal antiviral prophylaxis (valganciclovir) for 3–6 months post-transplant to prevent primary CMV disease.

Question 39: What is the significance of donor-specific antibodies (DSA) detected post-transplant?

They are associated with antibody-mediated rejection and reduced graft survival (Correct answer)
They indicate successful engraftment
They improve graft tolerance
They have no clinical significance

Correct answer: They are associated with antibody-mediated rejection and reduced graft survival

De novo DSAs are associated with antibody-mediated rejection (AMR) and are linked to worse long-term graft outcomes.

Question 40: Which drug interaction is most clinically significant for transplant patients taking tacrolimus?

CYP3A4 inhibitors such as fluconazole significantly increase tacrolimus levels (Correct answer)
Concurrent use of aspirin
Vitamin C supplementation
Concurrent use of beta blockers

Correct answer: CYP3A4 inhibitors such as fluconazole significantly increase tacrolimus levels

Tacrolimus is metabolized by CYP3A4, so inhibitors like azole antifungals can dramatically increase tacrolimus blood levels, risking toxicity.

Question 41: Which cytokine plays the most central role in T-cell activation during acute rejection?

IL-2 (Correct answer)
IL-10
IL-4
TNF-alpha

Correct answer: IL-2

IL-2 is the primary growth factor for T lymphocytes and plays a central role in T-cell proliferation during acute rejection episodes.

Question 42: A liver transplant patient develops elevated bilirubin and alkaline phosphatase with a normal hepatic artery Doppler 6 weeks post-transplant. MRCP shows a stricture at the biliary anastomosis. The BEST initial treatment is:

Emergency surgical revision
Increase immunosuppression to treat rejection
Endoscopic retrograde cholangiopancreatography (ERCP) with balloon dilation and stenting (Correct answer)
Liver re-transplantation

Correct answer: Endoscopic retrograde cholangiopancreatography (ERCP) with balloon dilation and stenting

Anastomotic biliary strictures post-liver transplant are first managed endoscopically with ERCP balloon dilation and stenting, which is effective in most cases.

Question 43: Mycophenolate mofetil (MMF) inhibits which enzyme to suppress lymphocyte proliferation?

Calcineurin
mTOR
Dihydrofolate reductase
Inosine monophosphate dehydrogenase (IMPDH) (Correct answer)

Correct answer: Inosine monophosphate dehydrogenase (IMPDH)

MMF inhibits IMPDH, blocking de novo purine synthesis which lymphocytes rely on exclusively for proliferation, making it lymphocyte-selective.

Question 44: What is the most important nursing assessment parameter in the first 24 hours after kidney transplantation?

Daily weight measurement only
Blood glucose monitoring every 4 hours
Oral intake documentation
Hourly urine output measurement (Correct answer)

Correct answer: Hourly urine output measurement

Hourly urine output is the most critical early indicator of graft function — sudden decrease can indicate vascular complications, obstruction, or rejection.

Question 45: Which transplant patient situation requires mandatory referral to social work?

Patient expresses inability to afford medications or housing instability (Correct answer)
Patient has questions about returning to work
Patient asks questions about medication side effects
Patient requests a second medical opinion

Correct answer: Patient expresses inability to afford medications or housing instability

Financial instability and housing insecurity are social determinants that directly threaten medication adherence and graft survival, requiring urgent social work intervention.

Question 46: A transplant recipient asks if they can get a flu shot. What is the most accurate nursing response?

Live attenuated vaccines are preferred for better immunity
Vaccines are unnecessary because immunosuppression prevents flu
Inactivated influenza vaccines are recommended annually; live vaccines are contraindicated (Correct answer)
All vaccines are contraindicated after transplantation

Correct answer: Inactivated influenza vaccines are recommended annually; live vaccines are contraindicated

Transplant recipients should receive inactivated vaccines (not live), including annual influenza vaccine, because live vaccines can cause disease in immunocompromised patients.

Question 47: Basiliximab is an induction agent that acts by blocking which interleukin receptor?

IL-6 receptor
IL-4 receptor
IL-17 receptor
IL-2 receptor (CD25) (Correct answer)

Correct answer: IL-2 receptor (CD25)

Basiliximab is a monoclonal antibody that blocks the IL-2 receptor (CD25) on activated T cells, preventing IL-2-driven proliferation.

Question 48: A transplant nurse uses the 'teach-back' method during patient education. What does this involve?

Having the patient take a written test
Teaching the patient and then reviewing the same content the next day
Teaching the same material multiple times in a row
Asking the patient to explain or demonstrate what they learned to confirm understanding (Correct answer)

Correct answer: Asking the patient to explain or demonstrate what they learned to confirm understanding

Teach-back involves asking patients to explain information in their own words or demonstrate skills, confirming comprehension rather than assuming it.

Question 49: Which topic is most critical to include in discharge education for a new kidney transplant recipient?

Signs and symptoms of rejection and when to seek immediate care (Correct answer)
Dietary restrictions for cholesterol management
How to apply for disability benefits
Exercise guidelines for returning to sports

Correct answer: Signs and symptoms of rejection and when to seek immediate care

Teaching rejection warning signs (decreased urine output, fever, graft tenderness, rising creatinine) and when to seek care is the most critical discharge education topic.

Question 50: Tacrolimus exerts its immunosuppressive effect by inhibiting which enzyme?

mTOR
Inosine monophosphate dehydrogenase
Janus kinase
Calcineurin (Correct answer)

Correct answer: Calcineurin

Tacrolimus inhibits calcineurin, preventing IL-2 transcription and thereby blocking T-cell activation and proliferation.

Question 51: What monitoring strategy is recommended for early detection of CMV infection in transplant recipients who are at intermediate risk (D+/R+ or D-/R+)?

Universal prophylaxis with valganciclovir for 12 months
Monthly CMV antigenemia testing (pp65) as the sole surveillance method
Clinical monitoring only, treating when symptoms develop
Pre-emptive therapy guided by regular CMV quantitative PCR surveillance (Correct answer)

Correct answer: Pre-emptive therapy guided by regular CMV quantitative PCR surveillance

Pre-emptive therapy uses quantitative PCR to detect rising CMV viremia before symptoms develop, allowing targeted antiviral treatment and avoiding unnecessary prolonged prophylaxis in intermediate-risk patients.

Question 52: During a living donor kidney evaluation, the potential donor is found to have a glomerular filtration rate (GFR) of 72 mL/min/1.73 m². The transplant team should:

Evaluate further with a 24-hour urine collection and repeat measurement (Correct answer)
Decline the donor; GFR must be >80 mL/min for donation
Proceed with donation since GFR >60 mL/min is acceptable
Immediately approve donation as the GFR is within normal limits

Correct answer: Evaluate further with a 24-hour urine collection and repeat measurement

A borderline GFR requires further evaluation including 24-hour urine for creatinine clearance and protein to ensure safe residual function post-donation.

Question 53: A heart transplant nurse is teaching a recipient about cardiac allograft vasculopathy (CAV). Which statement BEST describes CAV?

CAV presents with chest pain identical to classic angina because the heart is re-innervated
CAV primarily affects the right coronary artery only
CAV is a diffuse, chronic immune-mediated coronary artery disease that is the leading cause of late graft loss in heart recipients (Correct answer)
CAV is an acute rejection episode that resolves with steroid treatment

Correct answer: CAV is a diffuse, chronic immune-mediated coronary artery disease that is the leading cause of late graft loss in heart recipients

CAV is a diffuse, concentric intimal hyperplasia of coronary vessels driven by chronic allograft immune injury and is the leading cause of death beyond the first year post-heart transplant.

Question 54: Which antifungal agent is most commonly used for prophylaxis against Candida infections in high-risk solid organ transplant recipients during the early post-transplant period?

Fluconazole (Correct answer)
Itraconazole
Micafungin
Amphotericin B deoxycholate

Correct answer: Fluconazole

Fluconazole is the standard prophylactic antifungal in high-risk transplant recipients (e.g., liver, small bowel) due to its established efficacy, oral bioavailability, and favorable safety profile.

Question 55: What is 'delayed graft function' (DGF) in kidney transplantation?

Rejection occurring within 24 hours
Failure to urinate intraoperatively
Gradual improvement of creatinine over 3 months
Need for dialysis within the first week post-transplant due to ATN (Correct answer)

Correct answer: Need for dialysis within the first week post-transplant due to ATN

DGF is defined as the need for dialysis in the first week post-transplant and is most commonly caused by ischemia-reperfusion injury leading to ATN.

Question 56: Which criterion must be met before a patient can be declared brain dead for organ donation purposes?

Cardiac arrest followed by resuscitation failure
Irreversible cessation of all brain functions including the brainstem confirmed by two physicians (Correct answer)
Flat EEG for 24 hours
Absent pupillary reflexes alone

Correct answer: Irreversible cessation of all brain functions including the brainstem confirmed by two physicians

Brain death requires irreversible cessation of all brain functions including the brainstem, confirmed by two qualified physicians using established clinical criteria.

Question 57: What is the primary role of HLA matching in solid organ transplantation?

To reduce the risk of immunologic rejection (Correct answer)
To determine organ size compatibility
To match blood types between donor and recipient
To assess organ function prior to transplant

Correct answer: To reduce the risk of immunologic rejection

HLA matching reduces the immunologic mismatch between donor and recipient, thereby lowering the risk of rejection.

Question 58: A heart transplant recipient experiences symptomatic bradycardia and hypotension in the immediate post-operative period. This is MOST likely due to:

Acute cellular rejection causing conduction abnormalities
Perioperative myocardial infarction
Tacrolimus-induced conduction block
Cardiac denervation, as the transplanted heart lacks autonomic innervation (Correct answer)

Correct answer: Cardiac denervation, as the transplanted heart lacks autonomic innervation

The transplanted heart is surgically denervated and lacks direct autonomic control, making it dependent on circulating catecholamines and prone to bradycardia requiring chronotropic support.

Question 59: Which donor characteristic increases the risk of disease transmission to the transplant recipient?

Donor hypertension
Donor age over 65
Cold ischemia time over 12 hours
Recent high-risk behaviors for bloodborne infections (Correct answer)

Correct answer: Recent high-risk behaviors for bloodborne infections

Recent high-risk behaviors (IV drug use, unprotected sex with multiple partners) increase the risk of bloodborne disease transmission despite negative donor testing.

Question 60: Which condition is BK polyomavirus nephropathy MOST likely to be mistaken for on kidney transplant biopsy, creating a diagnostic challenge?

Chronic antibody-mediated rejection
Recurrent focal segmental glomerulosclerosis
CNI toxicity
Acute cellular rejection (T-cell mediated) (Correct answer)

Correct answer: Acute cellular rejection (T-cell mediated)

BK nephropathy causes tubulitis and interstitial nephritis that histologically mimics acute T-cell-mediated rejection, but treatment differs radically — steroids for rejection vs. immunosuppression reduction for BK.

Question 61: Which finding in a liver transplant recipient at post-operative day 3 would be MOST concerning for primary non-function (PNF)?

Mild ascites on ultrasound
AST >5,000 IU/L with coagulopathy and rising creatinine (Correct answer)
ALT 500 IU/L with improving trend
Serum bilirubin 3.2 mg/dL

Correct answer: AST >5,000 IU/L with coagulopathy and rising creatinine

Markedly elevated transaminases (>5,000 IU/L) combined with coagulopathy and renal failure in the early post-transplant period are hallmarks of primary non-function, a graft-threatening emergency.

Question 62: A kidney transplant patient presents with fever, graft tenderness, and rising serum creatinine 10 days post-transplant. What is the most likely diagnosis?

Cyclosporine toxicity
Renal artery stenosis
Urinary tract infection
Acute cellular rejection (Correct answer)

Correct answer: Acute cellular rejection

Fever, graft tenderness, and rising creatinine in the first weeks post-transplant are classic signs of acute cellular rejection requiring biopsy confirmation.

Question 63: Which psychological condition is most commonly seen in transplant recipients awaiting an organ on the waiting list?

Schizophrenia
Mania
Obsessive-compulsive disorder
Depression and anxiety (Correct answer)

Correct answer: Depression and anxiety

Depression and anxiety are highly prevalent in transplant candidates and recipients, driven by uncertainty, health burden, and life disruption, requiring regular psychosocial screening.

Question 64: Which electrolyte abnormality is a well-known adverse effect of tacrolimus and cyclosporine?

Hypocalcemia
Hyperkalemia
Hypomagnesemia and hyperkalemia (Correct answer)
Hyponatremia

Correct answer: Hypomagnesemia and hyperkalemia

Calcineurin inhibitors commonly cause both hyperkalemia (via reduced renal potassium excretion) and hypomagnesemia (via renal wasting).

Question 65: What does 'first-person consent' mean in the context of organ donation in the US?

An individual's documented decision to donate (e.g., on a driver's license) is legally binding (Correct answer)
A physician must obtain consent before any family member
Family must provide first consent before a donor registry is consulted
Only next-of-kin can authorize donation

Correct answer: An individual's documented decision to donate (e.g., on a driver's license) is legally binding

First-person consent means a person's registered decision to donate is legally binding and cannot be overridden by family, though family collaboration is still encouraged.

Question 66: Which of the following cytomegalovirus (CMV) serostatus combinations carries the HIGHEST risk for CMV disease post-transplant?

Donor positive / Recipient positive (D+/R+)
Donor positive / Recipient negative (D+/R-) (Correct answer)
Donor negative / Recipient positive (D-/R+)
Donor negative / Recipient negative (D-/R-)

Correct answer: Donor positive / Recipient negative (D+/R-)

A CMV-seropositive donor transplanted into a seronegative recipient (D+/R-) poses the highest risk because the recipient has no pre-existing immunity.

Question 67: When should a transplant nurse administer the morning dose of tacrolimus relative to blood draws for trough levels?

After the blood draw is collected (Correct answer)
Two hours after the blood draw
It does not matter — timing has no effect on levels
Before the blood draw is collected

Correct answer: After the blood draw is collected

Tacrolimus trough levels must be drawn before administering the morning dose to accurately reflect the lowest drug concentration during the dosing interval.

Question 68: Which apnea test finding confirms brain death during donor evaluation?

Spontaneous respirations observed during the test
Decreased oxygen saturation alone
No spontaneous respirations with PaCO2 rising to ≥60 mmHg or 20 mmHg above baseline (Correct answer)
Positive corneal reflex

Correct answer: No spontaneous respirations with PaCO2 rising to ≥60 mmHg or 20 mmHg above baseline

A positive apnea test for brain death requires no spontaneous respirations despite a PaCO2 ≥60 mmHg or 20 mmHg above baseline, confirming absent brainstem function.

Question 69: There are several signs of decreased cardiac output in heart recipients.

Jugular venousdistention (Correct answer)
Decreased BUN and serum creatinine
Hypertension
Metabolic alkalosis

Correct answer: Jugular venousdistention

Jugular venous distention (JVD) is a clinical sign indicating increased central venous pressure, which can be a manifestation of fluid overload or right-sided heart failure. In heart transplant recipients, decreased cardiac output can lead to fluid backup and elevated venous pressures, making JVD a key indicator of this complication.

Question 70: What is the primary purpose of the UNOS (United Network for Organ Sharing)?

Managing the national organ transplant system and waitlist (Correct answer)
Funding transplant research
Training transplant nurses
Performing transplant surgeries

Correct answer: Managing the national organ transplant system and waitlist

UNOS manages the national organ transplant system under contract with HRSA, maintaining the waitlist and matching policies.

Question 71: Which screening test should be performed on all transplant candidates to detect latent tuberculosis prior to transplantation?

Chest X-ray alone is sufficient for TB screening
Tuberculin skin test (TST) or interferon-gamma release assay (IGRA) (Correct answer)
Sputum AFB culture from three consecutive samples
Bronchoscopy with BAL for mycobacterial culture

Correct answer: Tuberculin skin test (TST) or interferon-gamma release assay (IGRA)

Both TST and IGRA (QuantiFERON-TB Gold) are recommended for pre-transplant latent TB screening, as immunosuppression post-transplant carries a significant risk of reactivating latent infection.

Question 72: The most likely diagnosis is intermittent hypoxemia and stridor in a lung recipient, which are alleviated by sputum coughing.

Inadequate bronchial anastomosis
Tracheobronchial stenosis (Correct answer)
Primary graft dysfunction
Pneumothorax

Correct answer: Tracheobronchial stenosis

Intermittent hypoxemia and stridor in a lung transplant recipient, especially when alleviated by sputum coughing, are highly indicative of tracheobronchial stenosis. This condition involves the narrowing of the airways, often at the anastomosis site after transplantation. The symptoms arise from airflow obstruction, and temporary relief with coughing suggests that mucus plugging or partial obstruction, commonly associated with stenosis, is being cleared.

Question 73: Under the Organ Procurement and Transplantation Network (OPTN) rules, who is legally responsible for a transplant program's compliance with OPTN policies?

The Centers for Medicare & Medicaid Services (CMS) alone
UNOS directly manages compliance for all centers
The Organ Procurement Organization (OPO) for that region
The hospital's transplant program and its designated transplant physicians/surgeons (Correct answer)

Correct answer: The hospital's transplant program and its designated transplant physicians/surgeons

OPTN membership obligates each transplant program — including its designated transplant physicians and hospital administration — to comply with OPTN policies, with the program bearing primary accountability.

Question 74: A cLean-catch midstream urine specimen for urinalysis

25 to 50
50 to 65
18 to 25 (Correct answer)
65 to 75

Correct answer: 18 to 25

This question is incomplete and lacks context, making a direct explanation for the answer '18 to 25' difficult in relation to 'A clean-catch midstream urine specimen for urinalysis'. Assuming there is missing information, this age range might refer to the typical age of kidney transplant recipients or donors, or perhaps a demographic group where certain medical conditions are prevalent. Without the full question, any explanation linking the prompt to the answer is speculative.

Question 75: What is the first-line treatment for acute cellular rejection confirmed by biopsy?

High-dose intravenous corticosteroids (pulse steroids) (Correct answer)
Start rituximab infusion
Initiate plasmapheresis
Increase maintenance tacrolimus dose only

Correct answer: High-dose intravenous corticosteroids (pulse steroids)

High-dose IV methylprednisolone (pulse steroids) is the first-line treatment for acute cellular rejection, typically given for 3–5 days.

Question 76: Calcineurin inhibitor nephrotoxicity can be distinguished from acute rejection by which finding?

CNI toxicity responds to pulse steroids
Both show the same histologic pattern on biopsy
CNI nephrotoxicity is associated with high drug levels and tubular vacuolization without significant inflammation (Correct answer)
Rejection always causes anuria while CNI toxicity does not

Correct answer: CNI nephrotoxicity is associated with high drug levels and tubular vacuolization without significant inflammation

CNI nephrotoxicity typically shows isometric tubular vacuolization on biopsy with elevated drug levels, while rejection shows inflammatory cell infiltration.

Question 77: A heart transplant patient is being evaluated six months post-transplant with an endomyocardial biopsy. The pathology report reads 'Grade 2R acute cellular rejection.' According to ISHLT grading, this indicates:

Mild rejection not requiring treatment
Moderate rejection requiring augmented immunosuppression (Correct answer)
No rejection; routine follow-up only
Severe rejection with hemodynamic compromise

Correct answer: Moderate rejection requiring augmented immunosuppression

Grade 2R (moderate) acute cellular rejection per ISHLT 2004 criteria typically warrants treatment with pulse steroids or augmented immunosuppression.

Question 78: Which immunologic test is performed before transplantation to detect preformed donor-specific antibodies?

Western blot
ELISA for ANA
Complement fixation test
Cross-match test (Correct answer)

Correct answer: Cross-match test

The cross-match test mixes recipient serum with donor lymphocytes to detect preformed donor-specific antibodies that could cause rejection.

Question 79: A post-liver transplant patient on prednisone and tacrolimus reports new-onset polydipsia, polyuria, and fatigue. Fasting glucose is 210 mg/dL. The MOST likely diagnosis is:

New-onset diabetes after transplantation (NODAT) (Correct answer)
Adrenal insufficiency from steroid withdrawal
Tacrolimus nephrotoxicity
Hepatitis C recurrence

Correct answer: New-onset diabetes after transplantation (NODAT)

New-onset diabetes after transplantation (NODAT) is common and is driven by glucocorticoid-induced insulin resistance and calcineurin inhibitor-mediated beta-cell toxicity.

Question 80: A heart transplant patient develops a new resting heart rate of 58 bpm with fatigue and dyspnea on post-operative day 10. What etiology should the nurse prioritize?

Sinus bradycardia from vagal tone
Donor heart denervation effect
Beta-blocker toxicity
Acute cellular rejection (Correct answer)

Correct answer: Acute cellular rejection

New fatigue and dyspnea with hemodynamic changes in the first weeks post-heart transplant are classic signs of acute cellular rejection until proven otherwise and require urgent endomyocardial biopsy.

Question 81: A lung transplant recipient develops a new obstructive pattern on pulmonary function testing at 18 months post-transplant with an FEV1 decline of 25% from baseline. This is MOST consistent with:

Acute cellular rejection
Bronchiolitis obliterans syndrome (BOS) (Correct answer)
Pneumonia
Pleural effusion

Correct answer: Bronchiolitis obliterans syndrome (BOS)

Bronchiolitis obliterans syndrome is the most common form of chronic lung allograft dysfunction, characterized by progressive obstructive airflow decline.

Question 82: A lung transplant recipient reports new-onset dyspnea and a 10% decline in FEV1 at the 12-month clinic visit. Which condition should the transplant nurse suspect?

Pneumocystis jirovecii pneumonia
Acute cellular rejection
Chronic lung allograft dysfunction (CLAD)/BOS (Correct answer)
Pulmonary embolism

Correct answer: Chronic lung allograft dysfunction (CLAD)/BOS

A persistent decline in FEV1 beyond the early post-transplant period is the hallmark of bronchiolitis obliterans syndrome (BOS), the most common form of chronic lung allograft dysfunction.

Question 83: Which of the following is the most important factor in determining a patient's risk for rejection in the first year after transplant?

Recipient age
Cold ischemia time
Number of HLA mismatches (Correct answer)
Donor BMI

Correct answer: Number of HLA mismatches

The number of HLA mismatches between donor and recipient is the most important immunologic factor determining rejection risk in the first year post-transplant.

Question 84: Donation after Circulatory Death (DCD) differs from Donation after Brain Death (DBD) in what key way?

DCD is only applicable in pediatric donors
DCD organs are only used for tissue donation
DCD occurs after cessation of cardiac function rather than brain death declaration (Correct answer)
DCD requires family refusal of brain death criteria

Correct answer: DCD occurs after cessation of cardiac function rather than brain death declaration

In DCD, organ donation proceeds after the planned withdrawal of life support and confirmation of circulatory death, rather than after brain death declaration.

Question 85: Which dietary instruction is important for transplant recipients to prevent foodborne infections?

Avoid raw or undercooked meats, unpasteurized products, and unwashed produce due to immunocompromised status (Correct answer)
Consume unpasteurized dairy products for probiotic benefits
Food safety precautions are only needed in the first 3 months
Raw sushi is acceptable if from reputable restaurants

Correct answer: Avoid raw or undercooked meats, unpasteurized products, and unwashed produce due to immunocompromised status

Immunocompromised transplant recipients must follow strict food safety practices because organisms like Salmonella, Listeria, and Cryptosporidium can cause severe or fatal infections.

Question 86: A patient taking tacrolimus is prescribed rifampin for tuberculosis. What effect should the transplant nurse anticipate?

Tacrolimus levels will decrease significantly due to CYP3A4 induction (Correct answer)
Tacrolimus will be contraindicated and must be stopped
Rifampin has no effect on tacrolimus levels
Tacrolimus levels will increase significantly

Correct answer: Tacrolimus levels will decrease significantly due to CYP3A4 induction

Rifampin is a potent CYP3A4 inducer that markedly accelerates tacrolimus metabolism, requiring significant dose increases to maintain therapeutic levels.

Question 87: A liver transplant patient taking mycophenolate mofetil (MMF) develops severe diarrhea. What is the MOST appropriate nursing response?

Recommend over-the-counter loperamide and continue MMF at the same dose
Advise the patient to increase dietary fiber to manage symptoms
Discontinue MMF immediately without consulting the team
Notify the transplant team; MMF dose reduction or conversion to enteric-coated mycophenolate sodium may be indicated (Correct answer)

Correct answer: Notify the transplant team; MMF dose reduction or conversion to enteric-coated mycophenolate sodium may be indicated

GI toxicity (diarrhea, nausea) is the most common MMF side effect and can lead to dehydration and non-adherence; dose reduction or formulation change requires transplant team evaluation to avoid compromising immunosuppression.

Question 88: A kidney transplant patient presents with fever, dysuria, and a positive urine culture for E. coli. The transplant nurse recognizes that urinary tract infections post-transplant are particularly dangerous because:

E. coli is universally resistant to all antibiotics in transplant patients
Immunosuppression masks symptoms and increases risk of urosepsis and pyelonephritis of the allograft (Correct answer)
They always lead to graft loss within 48 hours
UTIs cause irreversible tacrolimus toxicity

Correct answer: Immunosuppression masks symptoms and increases risk of urosepsis and pyelonephritis of the allograft

Immunosuppression blunts the febrile and inflammatory response, allowing UTIs to progress rapidly to urosepsis or allograft pyelonephritis before clinical recognition.

Question 89: What is the primary mechanism by which trimethoprim-sulfamethoxazole provides prophylaxis against Toxoplasma gondii in transplant recipients?

It inhibits folate synthesis, which is essential for Toxoplasma replication (Correct answer)
It disrupts the parasite's cell membrane permeability
It stimulates innate immune recognition of the parasite
It blocks Toxoplasma entry into host macrophages

Correct answer: It inhibits folate synthesis, which is essential for Toxoplasma replication

TMP-SMX inhibits dihydrofolate reductase and dihydropteroate synthase, blocking folate synthesis required for Toxoplasma DNA replication, providing concurrent PCP and toxoplasma prophylaxis.

Question 90: A transplant nurse is educating a kidney recipient on sun protection. What is the primary reason transplant patients must rigorously avoid sun exposure?

Immunosuppression dramatically increases risk of skin cancers, especially squamous cell carcinoma (Correct answer)
Tacrolimus causes photosensitivity rashes
Sun exposure reduces drug absorption
UV light causes organ rejection

Correct answer: Immunosuppression dramatically increases risk of skin cancers, especially squamous cell carcinoma

Transplant recipients have up to 100 times increased risk of squamous cell carcinoma due to chronic immunosuppression impairing immune surveillance.

Question 91: A liver transplant recipient reports drinking alcohol occasionally. What is the most appropriate nursing response?

Occasional alcohol is only concerning if liver enzymes are elevated
Alcohol is absolutely contraindicated after liver transplantation due to risk of graft injury and recurrence of alcoholic liver disease (Correct answer)
Advise the patient to limit to one drink per week
Moderate alcohol is acceptable after liver transplantation

Correct answer: Alcohol is absolutely contraindicated after liver transplantation due to risk of graft injury and recurrence of alcoholic liver disease

Alcohol is contraindicated after liver transplantation because it can damage the graft and cause recurrence of alcoholic liver disease, threatening graft survival.

Question 92: A kidney transplant recipient expresses guilt about their donor's death. What is the most therapeutic nursing response?

Acknowledge the patient's feelings, normalize them, and offer connection to counseling or donor family support programs (Correct answer)
Tell the patient they should feel grateful, not guilty
Redirect the patient to focus on their recovery
Explain to the patient that guilt is irrational

Correct answer: Acknowledge the patient's feelings, normalize them, and offer connection to counseling or donor family support programs

Survivor guilt is a recognized psychological response in transplant recipients; acknowledging feelings, normalizing them, and offering support resources is the therapeutic approach.

Question 93: A renal transplant nurse notes a recipient's urine output drops from 200 mL/hr to 20 mL/hr at post-operative hour 6. What is the PRIORITY intervention?

Increase IV fluid rate to 300 mL/hr
Call for emergent dialysis
Check for Foley catheter kinking or obstruction first (Correct answer)
Administer furosemide 40 mg IV

Correct answer: Check for Foley catheter kinking or obstruction first

The first step in evaluating sudden oliguria post-transplant is to rule out a mechanical cause such as Foley catheter obstruction, which is common and easily correctable.

Question 94: Which immunosuppressant works by blocking the costimulatory signal required for T-cell activation?

Mycophenolate mofetil
Prednisone
Tacrolimus
Belatacept (Correct answer)

Correct answer: Belatacept

Belatacept is a CTLA-4 Ig fusion protein that blocks the CD28-B7 costimulatory pathway, preventing full T-cell activation without antigen signal blockade.

Question 95: A transplant patient says they cannot afford their medications. What is the most appropriate nursing action?

Document the concern and continue without intervention
Connect the patient with social work, patient assistance programs, and transplant coordinators to address financial barriers (Correct answer)
Advise the patient to use half doses to stretch their supply
Advise the patient to skip non-critical medications to save money

Correct answer: Connect the patient with social work, patient assistance programs, and transplant coordinators to address financial barriers

Financial barriers to medication access are a major adherence threat — the transplant team's social worker and patient assistance programs must be engaged immediately.

Question 96: Post-liver transplant, a patient develops fever, right upper quadrant pain, and elevated liver enzymes on day 10. Doppler ultrasound shows absent hepatic artery flow. This finding is MOST consistent with:

Primary non-function
Hepatic artery thrombosis (Correct answer)
Acute cellular rejection
Biliary anastomotic leak

Correct answer: Hepatic artery thrombosis

Hepatic artery thrombosis typically presents with fever, elevated enzymes, and absent arterial flow on Doppler in the early post-operative period.

Question 97: Which of the following is a goal of patient evaluation for solid organ transplantation?

To evaluate the patient's ability to comply with long-term posttransplant follow up requirements
To determine if there are comorbidities that would contraindicate transplantation
All of the above (Correct answer)
To determine if there are other options for managing the current disease

Correct answer: All of the above

Patient evaluation for solid organ transplantation is a comprehensive process that addresses multiple critical aspects. It aims to determine if alternative treatments exist, assess the patient's ability to adhere to complex post-transplant regimens, and identify any comorbidities that could contraindicate transplantation or compromise its success. All these factors are crucial for successful transplant outcomes.

Question 98: The insulin type that is most frequently used to manage hyperglycemia following heart transplantation is

Intermediate-acting NPH insulin, Humulin N, or Novolin N.
Long-acting (glargine) Lantus insulin
Short-acting regular insulin, such as Novolin R. (Correct answer)
Rapid-acting (lispro H) Humalog or (aspart) Novolog

Correct answer: Short-acting regular insulin, such as Novolin R.

Short-acting regular insulin (e.g., Novolin R) is frequently used to manage acute hyperglycemia in hospitalized patients, including those post-heart transplantation. Its predictable onset and duration allow for precise dose adjustments based on blood glucose levels, which is crucial when patients may have variable nutritional intake or are receiving corticosteroids that can significantly elevate blood sugar. Rapid-acting insulins might be too quick for consistent control in this setting, while intermediate and long-acting insulins are typically for basal coverage.

Question 99: Which factor most significantly limits the acceptable cold ischemia time for heart transplantation compared to kidney transplantation?

Heart transplants require more extensive HLA matching
Heart size compatibility requirements
The heart's sensitivity to ischemia makes the acceptable cold ischemia time much shorter (4–6 hours vs. 24–36 hours) (Correct answer)
Cardiac preservation solutions are less effective

Correct answer: The heart's sensitivity to ischemia makes the acceptable cold ischemia time much shorter (4–6 hours vs. 24–36 hours)

The heart is highly sensitive to ischemic injury, limiting acceptable cold ischemia time to approximately 4–6 hours, compared to 24–36 hours for kidneys.

Question 100: What is the primary purpose of performing a liver biopsy on a donor liver before transplantation?

To evaluate for hepatitis C
To assess the degree of hepatic steatosis, which affects graft function (Correct answer)
To match histocompatibility antigens
To detect rejection before transplant

Correct answer: To assess the degree of hepatic steatosis, which affects graft function

Donor liver biopsy primarily assesses macrovascular steatosis — livers with greater than 30–40% steatosis have increased risk of primary non-function.

Question 101: When educating a renal transplant recipient about food safety, which instruction is MOST important due to immunosuppression?

Avoid all raw fruits and vegetables permanently
Limit fluid intake to prevent graft hypertension
Consume only pasteurized dairy products and avoid raw shellfish (Correct answer)
Use separate cutting boards for raw meat and produce

Correct answer: Consume only pasteurized dairy products and avoid raw shellfish

Immunosuppressed transplant recipients are at high risk for Listeria and other foodborne pathogens, making avoidance of unpasteurized dairy and raw shellfish a critical safety measure.

Question 102: What is the primary role of the transplant coordinator in patient care?

To evaluate organ allocation decisions
To prescribe immunosuppressive medications
To serve as the primary point of contact, coordinating care across the transplant team and providing patient education and support (Correct answer)
To perform organ procurement surgeries

Correct answer: To serve as the primary point of contact, coordinating care across the transplant team and providing patient education and support

The transplant coordinator is the central communication hub for the patient, coordinating care across surgeons, nephrologists, pharmacists, social workers, and other team members.

Question 103: Which class of HLA antigens is most important in kidney transplant matching?

HLA-B only
HLA-DR (Correct answer)
HLA-A only
HLA-C

Correct answer: HLA-DR

HLA-DR matching is considered the most clinically important in kidney transplantation due to its strong association with acute rejection rates and graft survival.

Question 104: Which preservation solution is most commonly used for kidney preservation during cold storage?

Normal saline
University of Wisconsin (UW) solution (Correct answer)
Phosphate-buffered saline
Lactated Ringer's solution

Correct answer: University of Wisconsin (UW) solution

University of Wisconsin (UW) solution is the gold standard preservation fluid for kidney cold storage due to its composition that reduces ischemic cell damage.

Question 105: Renal artery stenosis after kidney transplantation typically presents with which clinical findings?

Gross hematuria and flank pain
Peripheral edema and weight gain
Fever and leukocytosis
Hypertension that is difficult to control and rising creatinine (Correct answer)

Correct answer: Hypertension that is difficult to control and rising creatinine

Transplant renal artery stenosis classically presents with refractory hypertension and worsening allograft function, often diagnosed by Doppler ultrasound.

Question 106: Which electrolyte abnormality is a well-known side effect of tacrolimus in kidney transplant recipients?

Hyperkalemia and hypomagnesemia (Correct answer)
Hyponatremia
Hypercalcemia
Hypermagnesemia

Correct answer: Hyperkalemia and hypomagnesemia

Tacrolimus causes hyperkalemia through impaired renal potassium excretion and hypomagnesemia through urinary magnesium wasting, both of which require monitoring and dietary management.

Question 107: A transplant nurse is educating a renal transplant patient about food safety. Which of the following instructions is MOST appropriate?

Avoid all fresh fruits and vegetables permanently
Raw shellfish and undercooked meats should be strictly avoided (Correct answer)
Grapefruit is safe in small amounts if taken away from medications
Probiotic yogurt is contraindicated in all immunosuppressed patients

Correct answer: Raw shellfish and undercooked meats should be strictly avoided

Immunosuppressed transplant recipients are at high risk for foodborne illness from pathogens like Listeria and Vibrio, making raw shellfish and undercooked meats dangerous.

Question 108: Acute cellular rejection is primarily mediated by which immune cells?

B lymphocytes
T lymphocytes (Correct answer)
Neutrophils
Natural killer cells

Correct answer: T lymphocytes

Acute cellular rejection is primarily mediated by T lymphocytes that recognize donor antigens and mount an immune response against the graft.

Question 109: How should a transplant nurse counsel a patient about sun exposure after transplantation?

Transplant recipients have significantly increased risk of skin cancer and must use high SPF sunscreen and protective clothing daily (Correct answer)
Sun protection is only needed in the first year post-transplant
Sun exposure is encouraged to increase vitamin D production
Only melanoma risk is increased — other skin exposures are safe

Correct answer: Transplant recipients have significantly increased risk of skin cancer and must use high SPF sunscreen and protective clothing daily

Immunosuppression dramatically increases skin cancer risk (up to 100-fold for squamous cell carcinoma), requiring lifelong sun protection and regular dermatologic follow-up.

Question 110: Which lifestyle modification is most important to counsel a transplant recipient about for long-term cardiovascular health?

Smoking cessation, regular exercise, and blood pressure management (Correct answer)
Avoiding all physical activity for the first year
Low-protein diet to reduce graft workload
Bed rest to protect the graft

Correct answer: Smoking cessation, regular exercise, and blood pressure management

Cardiovascular disease is the leading cause of death in transplant recipients, so smoking cessation, exercise, and BP management are paramount lifestyle counseling topics.

Question 111: Which of the following best describes 'hyperacute rejection' in solid organ transplantation?

Pre-formed recipient antibodies cause graft thrombosis within minutes to hours of reperfusion (Correct answer)
NK cell-mediated rejection occurring in the first 24 hours
Chronic fibrosis of the graft occurring years after transplant
T-cell mediated rejection occurring 5-7 days post-transplant

Correct answer: Pre-formed recipient antibodies cause graft thrombosis within minutes to hours of reperfusion

Hyperacute rejection is caused by pre-formed donor-specific antibodies that bind immediately upon reperfusion, activating complement and causing microvascular thrombosis.

Question 112: Panel Reactive Antibody (PRA) levels above what percentage indicate a highly sensitized transplant candidate?

10%
80% (Correct answer)
20%
50%

Correct answer: 80%

A PRA of 80% or higher indicates a highly sensitized patient with many preformed antibodies, making it difficult to find a compatible donor.

Question 113: A kidney transplant nurse notes a patient's tacrolimus trough level is 18 ng/mL (target 8–12). What is the priority nursing action?

Obtain a urine culture
Hold the next dose and notify the transplant physician (Correct answer)
Double the next tacrolimus dose
Administer the next dose as scheduled

Correct answer: Hold the next dose and notify the transplant physician

A supratherapeutic tacrolimus level increases nephrotoxicity and neurotoxicity risk; the physician must be notified to adjust dosing.

Question 114: A drop in central venous pressure after heart transplantation may be due to

Cardiac tamponade
Low intravascular volume (Correct answer)
Thombus obstruction
Increased intravascular volume

Correct answer: Low intravascular volume

Central Venous Pressure (CVP) reflects the pressure in the right atrium and is an indicator of right ventricular preload. A drop in CVP typically signifies decreased preload, meaning there is insufficient blood volume returning to the heart. The most common cause of decreased intravascular volume (hypovolemia), which can result from bleeding, dehydration, or inadequate fluid replacement post-surgery. Conditions like cardiac tamponade or increased intravascular volume would generally cause an *increase* in CVP.

Question 115: Which of the following patients must be assigned to a surgical unit nurse who is transferred to the general unit?

Heart Failure
Thyrotoxicosis
New onset Type II- Diabetes
Emergency appendectomy (Correct answer)

Correct answer: Emergency appendectomy

A nurse transferred from a surgical unit would possess specialized skills and experience in surgical patient care. An emergency appendectomy patient requires post-operative care directly related to surgical recovery, making this assignment the most appropriate and within the nurse's immediate area of expertise compared to general medical conditions.

Question 116: Which statement accurately describes maintenance immunosuppression in transplantation?

It is weaned off after 1 year post-transplant
It is given only during rejection episodes
It consists of lifelong medications to prevent rejection (Correct answer)
It is only required for high-immunologic-risk patients

Correct answer: It consists of lifelong medications to prevent rejection

Maintenance immunosuppression consists of lifelong medications that continuously suppress the immune system to prevent rejection of the transplanted organ.

Question 117: When counseling a female kidney transplant recipient of childbearing age about pregnancy, the transplant nurse should emphasize that:

Pregnancy is absolutely contraindicated for at least 10 years post-transplant
Mycophenolate mofetil must be discontinued before conception due to teratogenicity (Correct answer)
Tacrolimus levels typically need to be increased during pregnancy
Breastfeeding is encouraged to reduce maternal immunosuppression needs

Correct answer: Mycophenolate mofetil must be discontinued before conception due to teratogenicity

Mycophenolate mofetil (MMF) is a known teratogen associated with congenital malformations and must be switched to azathioprine at least 6 weeks before conception.

Question 118: Which post-transplant complication is caused by lymphatic disruption during surgery and typically presents as a fluid collection near the kidney?

Lymphocele (Correct answer)
Hematoma
Perinephric abscess
Urinoma

Correct answer: Lymphocele

Lymphocele is a collection of lymphatic fluid that forms near the transplanted kidney due to lymphatic disruption during surgery and may compress the ureter or iliac vein.

Question 119: Chest tube drainage shouldn't go over a certain amount while assessing postoperative mediastinal hemorrhage.

400 mL in 6 hours
300 mL in 1 to 3 hours
200 mL in 2 to 6 hours (Correct answer)
500 mL in 4 hours

Correct answer: 200 mL in 2 to 6 hours

Postoperative mediastinal hemorrhage is a serious complication following cardiac surgery. While specific thresholds can vary, chest tube drainage exceeding 200 mL in 2 to 6 hours, or 100 mL/hour for several consecutive hours, is generally considered a significant amount that warrants immediate assessment and potential intervention to prevent further complications.

Question 120: What is the nurse's priority action when a kidney transplant patient reports no urine output 2 hours post-operatively?

Encourage oral fluid intake
Assess catheter patency, check vitals, and notify the surgeon immediately (Correct answer)
Wait and reassess in 2 hours
Administer furosemide IV without orders

Correct answer: Assess catheter patency, check vitals, and notify the surgeon immediately

Anuria post-kidney transplant may indicate surgical complications, vascular thrombosis, or urinary obstruction — all require immediate evaluation.

Question 121: Which medication is used as induction therapy in transplantation and works by depleting T lymphocytes?

Anti-thymocyte globulin (ATG) (Correct answer)
Mycophenolate mofetil
Tacrolimus
Prednisone

Correct answer: Anti-thymocyte globulin (ATG)

Anti-thymocyte globulin (ATG) is a polyclonal antibody used for induction that rapidly depletes T lymphocytes, reducing the risk of early acute rejection.

Question 122: The typical length of a kidney transplant patient's hospital stay is

7 to 10 days (Correct answer)
19 to 32 days
55 to 72 days
12 to 14 days

Correct answer: 7 to 10 days

Following a kidney transplant, patients typically have a hospital stay of approximately 7 to 10 days. This period is essential for close monitoring of the new kidney's function, managing post-operative pain, initiating and adjusting immunosuppressive medications, and providing comprehensive education on post-transplant care. This timeframe allows for initial graft stability and addresses immediate complications before the patient is discharged.

Question 123: A liver transplant patient on mycophenolate mofetil (MMF) reports persistent diarrhea. The nurse should first:

Add loperamide and continue MMF unchanged
Switch to enteric-coated mycophenolate sodium to reduce GI side effects (Correct answer)
Stop MMF immediately
Reduce tacrolimus trough level

Correct answer: Switch to enteric-coated mycophenolate sodium to reduce GI side effects

Enteric-coated mycophenolate sodium delivers the drug to the small intestine, reducing upper GI side effects including diarrhea.

Question 124: Warm ischemia time in transplantation refers to which period?

Time from organ cooling to transplantation
Time the organ spends at room temperature during anastomosis
Time between brain death and family consent
Time from circulatory arrest to organ cooling in DCD, or from cross-clamp to reperfusion in DBD (Correct answer)

Correct answer: Time from circulatory arrest to organ cooling in DCD, or from cross-clamp to reperfusion in DBD

Warm ischemia time is when the organ lacks adequate perfusion at body temperature — in DCD donors this begins at circulatory arrest, and minimizing it is critical.

Question 125: A pancreas transplant patient develops hyperglycemia and elevated serum amylase/lipase 2 weeks post-transplant with a normal kidney function (simultaneous pancreas-kidney recipient). This is MOST suggestive of:

Pancreas allograft rejection or pancreatitis (Correct answer)
Surgical anastomotic leak from the bowel
Cytomegalovirus hepatitis
Kidney allograft rejection

Correct answer: Pancreas allograft rejection or pancreatitis

In simultaneous pancreas-kidney (SPK) transplant, rising glucose combined with elevated pancreatic enzymes suggests pancreas rejection or graft pancreatitis.

Question 126: Which type of rejection occurs within minutes to hours after transplantation and is caused by preformed antibodies?

Accelerated acute rejection
Acute cellular rejection
Chronic rejection
Hyperacute rejection (Correct answer)

Correct answer: Hyperacute rejection

Hyperacute rejection occurs within minutes to hours due to preformed recipient antibodies against donor antigens, causing immediate graft failure.

Question 127: Post-transplant erythrocytosis (PTE) in kidney transplant recipients is best managed by which medication class?

Diuretics
Calcium channel blockers
ACE inhibitors or angiotensin receptor blockers (Correct answer)
Erythropoiesis-stimulating agents

Correct answer: ACE inhibitors or angiotensin receptor blockers

ACE inhibitors and ARBs effectively reduce erythrocytosis in post-transplant patients by decreasing erythropoietin-stimulated red cell production.

Question 128: Chronic allograft nephropathy is characterized by which pathological finding on biopsy?

Hyperacute vascular thrombosis
Neutrophilic infiltration
Interstitial fibrosis and tubular atrophy (Correct answer)
Granulomatous inflammation

Correct answer: Interstitial fibrosis and tubular atrophy

Chronic allograft nephropathy is characterized by interstitial fibrosis and tubular atrophy, reflecting cumulative immune and non-immune injury over time.

Question 129: A deceased-donor organ allocation nurse receives a kidney offer for a highly sensitized patient with a panel reactive antibody (PRA) of 98%. What is the MOST critical pre-transplant test to perform?

ABO blood typing repeat
HLA-DR matching only
Virtual or prospective crossmatch (Correct answer)
Renal biopsy of the donor kidney

Correct answer: Virtual or prospective crossmatch

In highly sensitized recipients, a virtual or prospective crossmatch is critical to detect donor-specific antibodies (DSA) that could cause hyperacute rejection.

Question 130: Which immunosuppressant is most associated with new-onset diabetes after transplantation (NODAT)?

Sirolimus
Tacrolimus (Correct answer)
Mycophenolate mofetil
Azathioprine

Correct answer: Tacrolimus

Tacrolimus has the highest association with new-onset diabetes after transplantation (NODAT) due to its toxic effects on pancreatic beta cells and insulin secretion.

Question 131: Which immunosuppressant is an mTOR inhibitor used in transplantation?

Azathioprine
Basiliximab
Sirolimus (Correct answer)
Cyclosporine

Correct answer: Sirolimus

Sirolimus (rapamycin) is an mTOR inhibitor that blocks the intracellular signaling pathway required for T-cell proliferation after IL-2 stimulation.

Question 132: The United Network for Organ Sharing (UNOS) kidney allocation system prioritizes candidates based on all of the following EXCEPT:

Time on the waiting list
Calculated panel reactive antibody (CPRA) level
Degree of HLA mismatch
Recipient's annual household income (Correct answer)

Correct answer: Recipient's annual household income

UNOS allocation is based on medical and immunological factors including wait time, HLA mismatch, CPRA, and geographic proximity — not financial status.

Question 133: A transplant recipient reports that their partner feels their life revolves entirely around the transplant. Which approach best addresses this psychosocial concern?

Advise the partner to accept the situation without complaint
Document the concern without intervention
Refer the couple to transplant-specific counseling or support groups to address caregiver burden (Correct answer)
Advise the patient to minimize medical appointments to reduce burden on the partner

Correct answer: Refer the couple to transplant-specific counseling or support groups to address caregiver burden

Caregiver burden is a recognized psychosocial issue in transplantation; referral to transplant-specific counseling or support groups addresses both patient and caregiver needs.

Question 134: A renal transplant patient on mycophenolate mofetil reports severe diarrhea and nausea. What is the most appropriate nursing intervention?

Reassure the patient that GI side effects are expected and will resolve
Document and notify the provider — dose reduction or switch to EC-MPS may be needed (Correct answer)
Administer an antiemetic and continue the current dose
Discontinue MMF immediately without provider notification

Correct answer: Document and notify the provider — dose reduction or switch to EC-MPS may be needed

GI toxicity is a common MMF side effect that may require dose reduction or conversion to enteric-coated mycophenolate sodium (EC-MPS) — the provider must be notified.

Question 135: Which complication is indicated by a sudden cessation of urine output, graft pain, and hematuria in an early post-kidney-transplant patient?

Urinary tract infection
Renal vein thrombosis (Correct answer)
Acute tubular necrosis
Lymphocele

Correct answer: Renal vein thrombosis

Sudden anuria with graft pain and hematuria in the early post-transplant period suggests renal vein thrombosis, a surgical emergency requiring immediate intervention.

Question 136: Post-transplant lymphoproliferative disorder (PTLD) is MOST strongly associated with which viral infection?

Epstein-Barr virus (EBV) (Correct answer)
BK polyomavirus
Cytomegalovirus (CMV)
Hepatitis C virus (HCV)

Correct answer: Epstein-Barr virus (EBV)

PTLD is strongly associated with EBV-driven B-cell proliferation occurring under immunosuppression, particularly in EBV-seronegative recipients of EBV-seropositive donors.

Question 137: A transplant recipient asks when it is safe to receive the inactivated influenza vaccine post-transplant. What is the recommended timing?

Influenza vaccine is permanently contraindicated in all transplant recipients
At least 3–6 months post-transplant when maintenance immunosuppression is stable (Correct answer)
Within the first 2 weeks post-transplant before immunosuppression takes effect
Immediately at discharge regardless of time post-transplant

Correct answer: At least 3–6 months post-transplant when maintenance immunosuppression is stable

Inactivated influenza vaccine is safe for transplant recipients but is most effective when given after the period of highest-intensity immunosuppression (3–6 months), when the immune response is more likely to be adequate.

Question 138: A pediatric liver transplant patient is transitioning to adult care. Which nursing intervention is MOST critical for successful transition?

Have parents continue managing medications indefinitely to ensure adherence
Structured transition program teaching self-management, medication adherence, and adult healthcare navigation starting at age 12–14 (Correct answer)
Delay transition until the patient requests it
Transfer all medical records before age 18 and end pediatric visits

Correct answer: Structured transition program teaching self-management, medication adherence, and adult healthcare navigation starting at age 12–14

Early, structured transition programs that gradually transfer self-management responsibility are evidence-based and reduce the high rate of graft loss seen during adolescent transition to adult care.

Question 139: Which clinical presentation in a kidney transplant recipient should prompt immediate evaluation for CMV disease rather than simple viremia?

CMV viremia with fever, leukopenia, thrombocytopenia, and organ-specific symptoms such as colitis or pneumonitis (Correct answer)
Low-level CMV PCR positivity in a D-/R- recipient without any symptoms
CMV IgG seroconversion without detectable viremia on PCR
Asymptomatic CMV viremia detected on routine weekly surveillance PCR

Correct answer: CMV viremia with fever, leukopenia, thrombocytopenia, and organ-specific symptoms such as colitis or pneumonitis

CMV disease (as opposed to asymptomatic viremia) is defined by end-organ involvement with constitutional symptoms; the combination of viremia plus tissue-invasive findings requires prompt initiation of intravenous ganciclovir.

Question 140: When assessing a transplant candidate's psychosocial readiness, which factor is considered an ABSOLUTE contraindication by most transplant programs?

History of non-compliance that has since been corrected
History of treated depression
Single marital status with adequate social support
Active substance use disorder with ongoing use and denial (Correct answer)

Correct answer: Active substance use disorder with ongoing use and denial

Active, ongoing substance use disorder — particularly with denial — represents an absolute contraindication at most centers because it directly predicts post-transplant non-adherence and poor outcomes.

Question 141: What does the term 'crossmatch' refer to in transplantation?

Evaluating HLA antigen similarity
Matching blood types between donor and recipient
Comparing organ size compatibility
Testing recipient serum against donor lymphocytes for preformed antibodies (Correct answer)

Correct answer: Testing recipient serum against donor lymphocytes for preformed antibodies

A crossmatch tests whether recipient serum contains antibodies that react against donor cells, predicting hyperacute rejection risk.

Question 142: Regulatory T cells (Tregs) play what role in transplant immunology?

They activate the complement cascade
They produce donor-specific antibodies
They promote rejection by activating cytotoxic T cells
They suppress immune responses and may promote graft tolerance (Correct answer)

Correct answer: They suppress immune responses and may promote graft tolerance

Regulatory T cells suppress immune responses against the graft and are being studied as a means to promote tolerance and reduce rejection.

Question 143: What is the role of an Organ Procurement Organization (OPO) in the transplant process?

It provides immunosuppressive medications to transplant recipients
It coordinates organ donation, evaluation, allocation, and procurement from deceased donors (Correct answer)
It manages the transplant waiting list
It performs transplant surgeries at regional hospitals

Correct answer: It coordinates organ donation, evaluation, allocation, and procurement from deceased donors

OPOs coordinate all aspects of deceased donor organ procurement, including family consent, donor evaluation, organ allocation, and logistics.

Question 144: A heart transplant patient is prescribed azathioprine. What lab value requires close monitoring?

Serum creatinine
Serum calcium
Complete blood count (CBC) (Correct answer)
Serum potassium

Correct answer: Complete blood count (CBC)

Azathioprine causes bone marrow suppression, so CBC monitoring is essential to detect leukopenia, thrombocytopenia, and anemia.

Question 145: Post-transplant lymphoproliferative disorder (PTLD) is most strongly associated with which viral infection?

Cytomegalovirus (CMV)
Hepatitis C virus
Epstein-Barr Virus (EBV) (Correct answer)
BK polyomavirus

Correct answer: Epstein-Barr Virus (EBV)

PTLD is most strongly associated with Epstein-Barr Virus (EBV), particularly in EBV-naive recipients receiving organs from EBV-seropositive donors.

Question 146: A patient awaiting a heart transplant has blood type O negative. This patient can receive a heart from:

Any ABO blood type donor
Only O negative donors
O negative and O positive donors only (Correct answer)
O and A donors only

Correct answer: O negative and O positive donors only

Blood type O is the universal donor for red cells, but for solid organs ABO compatibility (not exact match) is required; O recipients can receive from O+ or O- donors.

Question 147: Which of the following is a common gastrointestinal side effect of mycophenolate mofetil (MMF)?

Peptic ulcer disease
Constipation and bloating
Esophageal stricture
Diarrhea, nausea, and abdominal cramping (Correct answer)

Correct answer: Diarrhea, nausea, and abdominal cramping

MMF commonly causes GI side effects including diarrhea, nausea, and cramping, which may be reduced by switching to enteric-coated mycophenolate sodium.

Question 148: What is the significance of donor-derived Strongyloides stercoralis infection in solid organ transplant recipients?

It is a benign self-limiting infection that resolves without treatment
It primarily causes graft dysfunction without systemic symptoms
It can cause fatal hyperinfection syndrome due to immunosuppression enabling unchecked larval dissemination (Correct answer)
It is easily prevented by standard post-transplant antifungal prophylaxis

Correct answer: It can cause fatal hyperinfection syndrome due to immunosuppression enabling unchecked larval dissemination

Strongyloides can be transmitted from an infected donor organ; under immunosuppression, the normal host-controlled autoinfection cycle becomes uncontrolled hyperinfection with potentially fatal gram-negative sepsis from larval gut translocation.

Question 149: Which complement pathway is primarily activated in antibody-mediated rejection?

Classical pathway (Correct answer)
Alternative pathway
Lectin pathway
Terminal pathway only

Correct answer: Classical pathway

The classical complement pathway is activated when donor-specific antibodies bind to graft endothelium, initiating the complement cascade in antibody-mediated rejection.

Question 150: In a febrile solid organ transplant recipient, why is empiric broad-spectrum antibiotic therapy typically initiated promptly before culture results are available?

Standard fever management guidelines recommend antibiotics for all patients with temperatures above 38°C
Early antibiotic therapy prevents opportunistic fungal superinfection in all transplant patients
Immunosuppressed patients lack the typical inflammatory response and can deteriorate rapidly from occult bacteremia (Correct answer)
Antibiotics reduce the risk of triggering acute rejection episodes associated with infection

Correct answer: Immunosuppressed patients lack the typical inflammatory response and can deteriorate rapidly from occult bacteremia

Immunosuppression blunts fever and other signs of infection, meaning the patient may already be severely ill by the time symptoms appear, requiring prompt empiric coverage to prevent septic shock.

Question 151: Which side effect is most associated with long-term tacrolimus use in transplant recipients?

Hypertension and nephrotoxicity (Correct answer)
Hepatotoxicity
Peripheral neuropathy
Gingival hyperplasia

Correct answer: Hypertension and nephrotoxicity

Long-term tacrolimus use commonly causes nephrotoxicity and hypertension, both of which require ongoing monitoring in transplant recipients.

Question 152: Which immunosuppressant is associated with the development of post-transplant lymphoproliferative disorder (PTLD)?

Belatacept
Azathioprine
Prednisone
Tacrolimus and overall high immunosuppression burden (Correct answer)

Correct answer: Tacrolimus and overall high immunosuppression burden

PTLD is associated with high overall immunosuppression burden, particularly with EBV-driven B-cell proliferation; no single drug is solely responsible.

Question 153: Which immunosuppressant is classified as an mTOR inhibitor and is known to impair wound healing?

Sirolimus (Correct answer)
Mycophenolate mofetil
Azathioprine
Tacrolimus

Correct answer: Sirolimus

Sirolimus (rapamycin) is an mTOR inhibitor that inhibits cell proliferation, which impairs wound healing and is often avoided or delayed in the early post-operative period.

Question 154: What is the purpose of machine perfusion technology in organ preservation?

To perform pre-implantation biopsy
To remove pathogens from the donor organ
To continuously perfuse the organ with oxygenated solution, reducing ischemic injury and improving viability (Correct answer)
To precondition the organ with immunosuppressive agents

Correct answer: To continuously perfuse the organ with oxygenated solution, reducing ischemic injury and improving viability

Machine perfusion continuously delivers oxygenated preservation solution to the organ, reducing cold ischemia injury and allowing viability assessment beyond static cold storage.

Question 155: A transplant coordinator is developing a transplant education program. Which teaching method is most effective for improving medication adherence?

Combining written materials, teach-back method, pill organizers, and follow-up reinforcement (Correct answer)
One verbal counseling session before discharge
Instructing family members only, not the patient
Providing a written medication list at discharge only

Correct answer: Combining written materials, teach-back method, pill organizers, and follow-up reinforcement

Multimodal education combining written materials, teach-back, organizational tools, and ongoing reinforcement is most effective for improving medication adherence in transplant recipients.

Question 156: The Kidney Donor Profile Index (KDPI) is used for what purpose?

To calculate the recipient's waiting time on the transplant list
To determine the recipient's risk of rejection
To estimate the quality and expected function of a deceased donor kidney relative to the donor pool (Correct answer)
To predict graft survival based on immunosuppression regimen

Correct answer: To estimate the quality and expected function of a deceased donor kidney relative to the donor pool

KDPI uses donor characteristics to estimate kidney quality — a higher KDPI indicates a greater risk of graft failure compared to the average donor kidney.

Question 157: The primary purpose of panel reactive antibody (PRA) testing in transplant candidates is to:

Identify pre-formed antibodies that could cause hyperacute rejection (Correct answer)
Determine the candidate's viral serology status
Assess the candidate's ABO blood type compatibility
Measure renal function prior to listing

Correct answer: Identify pre-formed antibodies that could cause hyperacute rejection

PRA testing detects pre-formed donor-specific antibodies (DSA) that can mediate hyperacute or antibody-mediated rejection upon exposure to the donor organ.

Question 158: End-stage liver disease and uremia are both related with a metabolic imbalance called

Respiratory alkalosis
Metabolic acidosis (Correct answer)
Respiratory acidosis
Metabolic alkalosis

Correct answer: Metabolic acidosis

Both end-stage liver disease and uremia (kidney failure) are strongly associated with metabolic acidosis. In liver disease, the impaired liver cannot adequately metabolize acidic byproducts, contributing to acid accumulation. In uremia, the kidneys lose their ability to excrete acids and reabsorb bicarbonate, leading to a buildup of acid in the blood. This results in a decreased blood pH, characteristic of metabolic acidosis.

Question 159: Mycophenolate mofetil (MMF) works primarily by inhibiting which enzyme?

Inosine monophosphate dehydrogenase (IMPDH) (Correct answer)
mTOR
Dihydrofolate reductase
Calcineurin

Correct answer: Inosine monophosphate dehydrogenase (IMPDH)

MMF inhibits IMPDH, blocking de novo purine synthesis and selectively suppressing lymphocyte proliferation.

Question 160: What is the significance of a positive cross-match in transplantation?

It indicates a good match and transplant should proceed
It indicates preformed antibodies that may cause rejection and is a contraindication (Correct answer)
It predicts long-term graft survival
It only affects kidney transplants

Correct answer: It indicates preformed antibodies that may cause rejection and is a contraindication

A positive cross-match indicates the recipient has preformed antibodies against donor antigens, which is generally a contraindication to transplantation due to high rejection risk.

Question 161: Which type of rejection occurs within minutes to hours after transplantation due to preformed antibodies?

Acute cellular rejection
Chronic rejection
Accelerated rejection
Hyperacute rejection (Correct answer)

Correct answer: Hyperacute rejection

Hyperacute rejection is mediated by preformed recipient antibodies against donor antigens and occurs immediately after perfusion.

Question 162: A transplant recipient is prescribed trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis. The PRIMARY indication for this medication in this population is:

Prevention of fungal esophagitis
Treatment of bacterial UTI
Prevention of cytomegalovirus infection
Prophylaxis against Pneumocystis jirovecii pneumonia (PCP) (Correct answer)

Correct answer: Prophylaxis against Pneumocystis jirovecii pneumonia (PCP)

TMP-SMX is the drug of choice for Pneumocystis jirovecii pneumonia prophylaxis in immunosuppressed transplant recipients, typically given for 6-12 months post-transplant.

Question 163: A heart transplant patient presents with endomyocardial biopsy showing grade 2R rejection. This corresponds to which type of rejection?

Moderate acute cellular rejection (Correct answer)
Hyperacute rejection
Mild rejection requiring no treatment
Chronic rejection

Correct answer: Moderate acute cellular rejection

Grade 2R on the ISHLT scale represents moderate acute cellular rejection, typically requiring augmented immunosuppression.

Question 164: A transplant nurse is preparing to administer anti-thymocyte globulin (ATG) for induction therapy. Which of the following precautions is MOST important?

Obtain a urine culture before each dose
Premedicate with acetaminophen, diphenhydramine, and corticosteroids to reduce infusion reactions (Correct answer)
Administer as a rapid IV push over 5 minutes
Monitor tacrolimus levels hourly during infusion

Correct answer: Premedicate with acetaminophen, diphenhydramine, and corticosteroids to reduce infusion reactions

ATG commonly causes infusion reactions including fever, chills, and hypotension; premedication with antipyretics, antihistamines, and steroids is standard practice.

Question 165: The direct pathway of allorecognition involves recipient T cells recognizing donor antigens presented by which cells?

Recipient B cells
Recipient antigen-presenting cells
Donor antigen-presenting cells (Correct answer)
Natural killer cells

Correct answer: Donor antigen-presenting cells

In the direct pathway, recipient T cells recognize intact donor MHC molecules presented directly on donor antigen-presenting cells.

Question 166: Which donor-derived infection poses the HIGHEST risk of undetected transmission during the standard infectious disease screening window period?

Cytomegalovirus (CMV)
Epstein-Barr virus (EBV)
Hepatitis B virus (HBV)
HIV during acute infection (NAT window period) (Correct answer)

Correct answer: HIV during acute infection (NAT window period)

HIV NAT testing has a window period during acute infection when viral load may be below detection limits, making recent high-risk donor behavior the primary residual transmission risk.

Question 167: Which electrolyte abnormality is MOST commonly associated with tacrolimus and cyclosporine use in transplant recipients?

Hyperkalemia (Correct answer)
Hypophosphatemia
Hyponatremia
Hypercalcemia

Correct answer: Hyperkalemia

Calcineurin inhibitors cause hyperkalemia by impairing renal tubular potassium excretion through aldosterone inhibition and direct tubular effects.

Question 168: Which statement best describes the expanded criteria donor (ECD) designation for kidneys?

ECD designation applies only to donors with cancer history
ECD kidneys are always declined by transplant centers
ECD kidneys are only from donors under age 18
ECD kidneys come from donors with risk factors associated with higher graft failure rates but may still benefit recipients (Correct answer)

Correct answer: ECD kidneys come from donors with risk factors associated with higher graft failure rates but may still benefit recipients

ECD kidneys come from donors with specific risk factors (age ≥60, or age 50–59 with comorbidities) that are associated with higher graft failure rates but may still provide benefit over dialysis.

Question 169: What dietary counseling should a transplant nurse provide to a patient taking tacrolimus about grapefruit?

Grapefruit only affects cyclosporine, not tacrolimus
Grapefruit is encouraged to boost immune function
One glass of grapefruit juice per day is acceptable
Grapefruit and grapefruit juice must be avoided because they inhibit CYP3A4 and can dramatically increase tacrolimus levels (Correct answer)

Correct answer: Grapefruit and grapefruit juice must be avoided because they inhibit CYP3A4 and can dramatically increase tacrolimus levels

Grapefruit inhibits intestinal CYP3A4 enzymes, unpredictably elevating tacrolimus blood levels and risking toxicity — it must be completely avoided.

Question 170: A transplant recipient presents with fever, productive cough, and CT findings showing bilateral ground-glass opacities three months post-transplant. Which organism should be highest on the differential?

Mycobacterium tuberculosis
Pneumocystis jirovecii (Correct answer)
Streptococcus pneumoniae
Candida albicans

Correct answer: Pneumocystis jirovecii

Ground-glass opacities on CT combined with fever and cough in the 1–6 month post-transplant window are classic for PCP, especially if prophylaxis was discontinued or inadequate.

Question 171: Which of the following is an absolute contraindication to living kidney donation?

Age over 55 years
BMI of 28 kg/m²
Active malignancy with metastatic disease (Correct answer)
Single kidney donor with a GFR of 90 mL/min/1.73m²

Correct answer: Active malignancy with metastatic disease

Active malignancy, particularly with metastatic potential, is an absolute contraindication to living donation due to the risk of transmitting cancer to the immunosuppressed recipient.

Question 172: A liver transplant recipient on tacrolimus is started on fluconazole for a fungal infection. What does the nurse anticipate?

Tacrolimus levels will increase due to CYP3A4 inhibition (Correct answer)
Mycophenolate levels will increase instead
No interaction; the drugs have different metabolism pathways
Tacrolimus levels will decrease significantly

Correct answer: Tacrolimus levels will increase due to CYP3A4 inhibition

Fluconazole is a potent CYP3A4 inhibitor that markedly reduces tacrolimus metabolism, causing drug levels to rise and increasing the risk of toxicity.

Question 173: Which serologic test must be negative in a potential organ donor to prevent transmission of HIV to the transplant recipient?

CMV IgG
HBsAg only
HIV-1/2 antibody and HIV NAT (nucleic acid testing) (Correct answer)
Anti-HCV antibody

Correct answer: HIV-1/2 antibody and HIV NAT (nucleic acid testing)

Both HIV antibody testing and nucleic acid testing (NAT) are performed on donors to minimize the window period and prevent HIV transmission to recipients.

Question 174: A potential organ donor has a history of treated hypertension and mild proteinuria. What step is most important before accepting the kidneys?

Perform a donor kidney biopsy to assess histologic quality (Correct answer)
Proceed with procurement without additional evaluation
Check the donor's family history only
Automatically decline the kidneys due to donor comorbidities

Correct answer: Perform a donor kidney biopsy to assess histologic quality

A biopsy helps assess the degree of glomerulosclerosis and arterial changes, informing the decision to use one or both kidneys or decline them.

Question 175: How long after transplantation should female recipients wait before attempting pregnancy?

6 months
At least 1–2 years, when graft function is stable and immunosuppression is minimized (Correct answer)
Pregnancy is permanently contraindicated after transplant
12 months

Correct answer: At least 1–2 years, when graft function is stable and immunosuppression is minimized

Transplant guidelines recommend waiting 1–2 years post-transplant until graft function is stable and immunosuppression is at maintenance levels before attempting pregnancy.

Question 176: Which opportunistic infection prophylaxis is standard for ALL solid organ transplant recipients in the first 3–6 months post-transplant?

Isoniazid for all recipients regardless of TB status
Fluconazole for Aspergillus
Trimethoprim-sulfamethoxazole (TMP-SMX) for Pneumocystis jirovecii (Correct answer)
Acyclovir for HSV only in seropositive donors

Correct answer: Trimethoprim-sulfamethoxazole (TMP-SMX) for Pneumocystis jirovecii

TMP-SMX is universally recommended for PCP prophylaxis in all solid organ transplant recipients during the high-immunosuppression period, and also provides coverage for Toxoplasma and Nocardia.

Question 177: Cyclosporine A is associated with which distinctive cosmetic side effect not seen with tacrolimus?

Moon face
Alopecia
Acne
Gingival hyperplasia (Correct answer)

Correct answer: Gingival hyperplasia

Gingival hyperplasia is a distinctive side effect of cyclosporine that is not typically seen with tacrolimus, making dental hygiene especially important.

Certified Clinical Transplant Nurse (CCTN)

The CCTN certification, administered by the American Board for Transplant Certification (ABTC), validates nursing expertise in pre- and post-transplant care, immunosuppression management, and long-term transplant patient support across solid organ transplantation.

175

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