A 35-year-old patient arrives at the Emergency Department in acute respiratory failure. What assessment information does the nurse prioritize as needing immediate action?

Choice A reason: Explaining that diarrhea is expected and that it is how the body gets rid of ammonia is accurate. Lactulose is often prescribed for patients with hepatic encephalopathy, and its purpose is to reduce blood ammonia levels by promoting bowel movements. Diarrhea is a common and anticipated side effect, as it helps eliminate ammonia from the body.

Choice B reason: Recommending Kaopectate for loose stools is not appropriate in this context. Kaopectate is an anti-diarrheal medication, and using it would counteract the effect of lactulose, which aims to promote bowel movements to reduce ammonia levels.

Choice C reason: Instructing the patient to stop taking the medication until stools firm up is incorrect. Lactulose should be continued as prescribed to maintain its therapeutic effect of reducing blood ammonia levels. Stopping the medication would negate its benefits and potentially worsen the patient's condition.

Choice D reason: Suggesting to send a stool specimen to the laboratory is unnecessary in this scenario. Diarrhea is an expected side effect of lactulose, and there is no indication that a stool specimen needs to be analyzed unless there are signs of infection or other complications.

Choice A reason: Immediate return to hemodialysis is not typically the first line of treatment for these symptoms. Hemodialysis is a renal replacement therapy used when the kidneys are not functioning adequately. While it may be necessary in some cases, the symptoms described suggest an infection rather than complete kidney failure.

Choice B reason: Immediate removal of the transplanted kidney is a drastic measure and is not the first step in managing these symptoms. This action would be considered only if there is clear evidence of irreversible graft failure or severe complications that cannot be managed with other treatments.

Choice C reason: Antibiotic therapy is

The correct answer. The symptoms of oliguria (low urine output), elevated temperature, increased blood pressure, and signs of fluid retention suggest an infection, which is a common complication after kidney transplantation due to the immunosuppressive medications that lower the immune system's ability to fight infections. Treating the infection with antibiotics is crucial to prevent further complications and preserve the function of the transplanted kidney.

Choice D reason: Increased doses of immunosuppressive drugs are not appropriate in this situation. While immunosuppressive drugs are essential to prevent organ rejection, increasing their dosage in the presence of an infection could further compromise the immune system and exacerbate the infection. The priority is to address the infection first.