A nurse is caring for a 65-year-old male client who is admitted to the emergency department for fatigue.

Exhibits

Which of the following findings indicate that the client may be experiencing transplant rejection? (Select all that apply)

Assessment of incision site

Assessment of lower extremities

Blood pressure

Sodium level

Answer and Explanation

Correct Answer : A,B,C

Choice A rationale:

Tenderness, redness, and swelling at the incision site can indicate an infection or transplant rejection, both of which require immediate medical attention to prevent further complications.

Choice B rationale:

Swelling in the lower extremities (edema) can be a sign of fluid retention, which may indicate kidney dysfunction or transplant rejection, necessitating prompt evaluation and intervention.

Choice C rationale:

Elevated blood pressure (180/90 mm Hg) can be a sign of transplant rejection, as the body may be responding to the new organ as a foreign object, leading to increased blood pressure.

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Correct Answer is C

Explanation

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.

A. Respiratory alkalosis. B. Respiratory acidosis. C. Metabolic acidosis. D. Metabolic alkalosis.

Correct Answer is B

Explanation

Choice A rationale

Respiratory alkalosis involves low carbon dioxide levels, which is not typical in COPD exacerbations.

Choice B rationale

Respiratory acidosis occurs due to impaired gas exchange and carbon dioxide retention in COPD.

Choice C rationale

Metabolic acidosis results from renal or metabolic issues, not primarily respiratory issues like in COPD.

Choice D rationale

Metabolic alkalosis involves high bicarbonate levels and is not typically associated with COPD exacerbations. .

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A nurse is caring for a 65-year-old male client who is admitted to the emergency department for fatigue. Exhibits Which of the following findings indicate that the client may be experiencing transplant rejection? (Select all that apply)

Nursing Test Bank

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A nurse is caring for a 65-year-old male client who is admitted to the emergency department for fatigue.

Exhibits

Which of the following findings indicate that the client may be experiencing transplant rejection? (Select all that apply)