A nurse is assessing a client who is 1 week postoperative, following a living donor kidney transplant. Which of the following findings indicates that the client is experiencing a transplant rejection of their new kidney?

Blood pressure 160/90 mmHg

Sodium 137 mg/dL

Urinary output of 100ml/hour

Creatinine 0.8 mg/Dl

Answer and Explanation

The Correct Answer is A

A. Blood pressure 160/90 mmHg: Hypertension is a sign of transplant rejection as it indicates compromised kidney function.

B. Sodium 137 mg/dL: This is within the normal range (135-145 mg/dL) and does not indicate rejection.

C. Urinary output of 100 ml/hour: Normal or high urinary output is expected after a successful transplant.

D. Creatinine 0.8 mg/dL: This level is within the normal range (0.6-1.2 mg/dL), indicating proper kidney function.

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Correct Answer is C

Explanation

A. Provide legal testimony on behalf of the client: While a SANE may document findings for legal purposes, they do not act as the client's legal representative.

B. Require the client to call the police: Reporting the incident is the client’s choice; the nurse should not coerce them.

C. Protect the client from further harm: The priority is to ensure the client's safety and well-being after a traumatic event.

D. Request the police to gather evidence: The SANE is responsible for collecting forensic evidence, not the police.

A. Flail chest B. Pulmonary contusion C. Fractured rib D. Tension pneumothorax

Correct Answer is D

Explanation

A. Flail chest: Flail chest involves paradoxical chest wall movement and is not associated with tracheal deviation.

B. Pulmonary contusion: This involves lung tissue injury with potential respiratory distress but does not cause tracheal deviation.

C. Fractured rib: While it can cause pain and respiratory distress, it does not lead to tracheal deviation or absent breath sounds.

D. Tension pneumothorax: Tension pneumothorax is characterized by respiratory distress, absent breath sounds on the affected side, and tracheal deviation away from the affected side. It occurs due to the accumulation of air in the pleural space, causing increased intrathoracic pressure and shifting of mediastinal structures.

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A nurse is assessing a client who is 1 week postoperative, following a living donor kidney transplant. Which of the following findings indicates that the client is experiencing a transplant rejection of their new kidney?

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