Choice A rationale

Temperature of 36.1°C (97.0°F) is below normal range and not indicative of organ rejection. Organ rejection often presents with elevated temperature due to the inflammatory response of the immune system attacking the transplanted organ.

Choice B rationale

Weight loss is not a common sign of acute organ rejection. Usually, fluid retention and associated weight gain can occur due to decreased kidney function.

Choice C rationale

Oliguria (reduced urine output) is a primary sign of kidney transplant rejection. It indicates that the transplanted kidney is not functioning properly, which is a critical indicator of rejection.

Choice D rationale

Insomnia is not typically associated with organ rejection. It can be related to stress or other factors but is not a direct sign of rejection.

Choice A rationale

Implementing a low-sodium diet helps reduce fluid retention and ascites in clients with cirrhosis, improving their condition.

Choice B rationale

Furosemide is a diuretic that helps reduce fluid overload and ascites in clients with cirrhosis by promoting excretion of excess fluid.

Choice C rationale

Warfarin is an anticoagulant and is not typically used in the management of cirrhosis as it could increase the risk of bleeding complications, especially in clients with liver dysfunction.

Choice D rationale

Measuring the client's abdominal girth is crucial for monitoring the progression of ascites, a common complication of cirrhosis.

Choice E rationale

Encouraging weight lifting is not advisable as it can exacerbate varices and increase the risk of bleeding in clients with cirrhosis.

Choice A rationale

Milky fluid often indicates chylothorax, a condition where lymphatic fluid leaks into the pleural space, and is not necessarily indicative of infection.

Choice B rationale

Bloody fluid may indicate trauma or malignancy but not necessarily infection.

Choice C rationale

Viscous fluid can be related to various conditions, including malignant effusion, but does not specifically indicate infection.

Choice D rationale

Purulent fluid is indicative of an infection as it contains pus, which is a collection of dead white blood cells, bacteria, and tissue debris.

Choice A rationale

A breast cancer survivor for 8 years without recurrence is generally considered for transplantation if otherwise healthy.

Choice B rationale

Age 65 is not an absolute contraindication for kidney transplantation. Many factors such as overall health status are considered.

Choice C rationale

Alcohol use disorder is a contraindication due to the potential for poor adherence to post-transplant care and medication, as well as the increased risk of liver damage.

Choice D rationale

Having a pacemaker is not an absolute contraindication for a kidney transplant; individuals with pacemakers can still be eligible for transplantation if otherwise healthy.

Choice A rationale

Bubbling in the water seal chamber with exhalation indicates that air is still being removed from the pleural space, which is expected with a pneumothorax and is not a cause for immediate concern.

Choice B rationale

Eyelets not being visible indicate that the chest tube is properly placed within the pleural space, not an urgent issue.

Choice C rationale

Movement of the trachea towards the unaffected side is a sign of tension pneumothorax, which requires immediate intervention as it can compromise respiratory function.

Choice D rationale

Crepitus in the area above and surrounding the insertion site indicates subcutaneous emphysema, which can occur but does not necessitate immediate provider notification unless severe.

Choice A rationale

Acidosis is a key characteristic of diabetic ketoacidosis due to the accumulation of ketoacids in the body from fat metabolism.

Choice B rationale

Low blood sugar is not associated with diabetic ketoacidosis; it is characterized by hyperglycemia.

Choice C rationale

Ketosis occurs in DKA due to the breakdown of fats instead of glucose for energy, leading to an accumulation of ketones.

Choice D rationale

Fluid overload is not typical of diabetic ketoacidosis; dehydration is more common due to osmotic diuresis.

Choice E rationale

Hyperglycemia is a hallmark of diabetic ketoacidosis, resulting from the lack of insulin and the consequent high levels of glucose in the blood.

Choice F rationale

Alkalosis is not associated with diabetic ketoacidosis; the condition is defined by metabolic acidosis. .

Choice A rationale

Withholding oral fluids and food is the priority because it reduces pancreatic stimulation and decreases the secretion of pancreatic enzymes, preventing further autodigestion and inflammation of the pancreas.

Choice B rationale

Auscultating the client's lungs is important to check for complications such as pleural effusion or atelectasis, but it is not the immediate priority after pain management.

Choice C rationale

Assisting the client to a side-lying position can help with comfort and may ease breathing, but it does not directly address the underlying issue of pancreatic inflammation.

Choice D rationale

Providing oral hygiene is essential for overall care but does not impact the acute management of pancreatitis.

Choice A rationale

Decreased serum lipase is not expected in acute pancreatitis; rather, lipase levels are typically elevated due to pancreatic enzyme leakage into the bloodstream.

Choice B rationale

Increased serum calcium is not a typical finding in acute pancreatitis; instead, hypocalcemia can occur due to fat necrosis and soap formation.

Choice C rationale

Decreased WBC is not expected; an elevated WBC count is common due to the inflammatory response associated with pancreatitis.

Choice D rationale

Increased serum amylase is a hallmark of acute pancreatitis as the damaged pancreas releases more amylase into the blood.

Choice A rationale

Obtaining a prescription for supplemental oxygen is the first action as hypoxia must be corrected immediately to ensure adequate tissue oxygenation.

Choice B rationale

Obtaining a prescription to administer intravenous fluids is essential to address dehydration but is secondary to correcting hypoxia.

Choice C rationale

Obtaining a prescription to administer insulin is crucial to manage hyperglycemia in diabetic ketoacidosis but not the initial step in this context.

Choice D rationale

Obtaining a prescription to check the client's glucose level is necessary for monitoring but does not address the immediate need for oxygenation.

Choice A rationale

Agitation is a common manifestation of hypoxemia due to insufficient oxygen reaching the brain and other vital organs.

Choice B rationale

Dysphagia, or difficulty swallowing, is not a typical manifestation of hypoxemia during an asthma attack.

Choice C rationale

Nausea can occur but is not a primary indicator of hypoxemia.

Choice D rationale

Hypotension may occur with severe hypoxemia but is not a direct manifestation of asthma-related hypoxemia.