A client who had a kidney transplant last week is receiving cyclosporine. This morning the client reports experiencing a headache and blurred vision. Based on which assessment finding should the nurse withhold the medication until the healthcare provider (HCP) is notified?

Temperature of 100.8° F (38.2° C).

Elevated blood urea nitrogen (BUN).

Renal output of 120 mL/hour.

Blood pressure 180/98 mm Hg.

Answer and Explanation

The Correct Answer is D

A. Temperature of 100.8° F (38.2° C): A mildly elevated temperature in a post-transplant client may suggest infection or early rejection, both of which warrant monitoring. However, this is not a direct reason to withhold cyclosporine, which is essential for preventing organ rejection.

B. Elevated blood urea nitrogen (BUN): Elevated BUN could indicate impaired renal function, which should be monitored during cyclosporine therapy. However, this alone is not an urgent reason to withhold the medication without further evaluation of kidney function trends and symptoms.

C. Renal output of 120 mL/hour: This is a healthy urine output and suggests good renal perfusion and function. It does not present any contraindication to continuing cyclosporine and supports that the transplanted kidney is functioning well.

D. Blood pressure 180/98 mm Hg: Hypertension is a known side effect of cyclosporine and can become severe. A blood pressure this high, especially when accompanied by headache and blurred vision, suggests possible cyclosporine-induced hypertensive crisis or toxicity, and warrants immediate withholding of the medication and notification of the HCP.

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Correct Answer is B

Explanation

A. Document the client's refusal of the medication at this time: While documentation is necessary if a medication is refused, the priority is to educate the client first. The nurse should explain the proper timing of sucralfate to promote understanding and adherence rather than simply accepting refusal.

B. Explain the need to take the medication at least 1 hour before meals: Sucralfate acts by forming a protective barrier over ulcerated mucosa and must be taken on an empty stomach for maximum effectiveness. Administering it one hour before meals ensures the stomach lining is properly coated before food intake.

C. Allow the client to take the medication up to 1 hour after breakfast: Taking sucralfate after a meal diminishes its ability to bind effectively to the mucosa. Food interferes with its action, so post-meal dosing is inappropriate for achieving therapeutic benefit.

D. Instruct the client to take it when the meal tray is delivered: Taking sucralfate at mealtime is too late for optimal therapeutic effect. At that point, gastric contents may interfere with its binding to ulcerated areas, reducing its protective action.

A. Schedule the medication to be given just before bedtime. B. Break the medication into small pieces and sprinkle onto food. C. Instruct the client to avoid dairy products for at least 30 minutes. D. Administer the medication thirty minutes prior to meals.

Correct Answer is D

Explanation

A. Schedule the medication to be given just before bedtime: Pyridostigmine should be timed to coincide with periods of increased activity, especially before meals, to improve muscle strength. Giving it at bedtime would not offer functional benefit unless the client experiences nighttime symptoms.

B. Break the medication into small pieces and sprinkle onto food: Pyridostigmine tablets are not designed to be crushed or split unless specifically directed. Altering the form may affect its absorption and reduce its effectiveness in managing symptoms of myasthenia gravis.

C. Instruct the client to avoid dairy products for at least 30 minutes: Dairy does not interfere significantly with the absorption or action of pyridostigmine. Dietary restrictions should be based on known drug-food interactions, which are not typically associated with pyridostigmine and dairy.

D. Administer the medication thirty minutes prior to meals: Administering pyridostigmine before meals helps enhance swallowing and chewing abilities, reducing the risk of aspiration. This timing optimizes muscle strength during eating, which is a high-risk activity for clients with myasthenia gravis.

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A client who had a kidney transplant last week is receiving cyclosporine. This morning the client reports experiencing a headache and blurred vision. Based on which assessment finding should the nurse withhold the medication until the healthcare provider (HCP) is notified?

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Correct Answer is D

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