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 A

Explanation

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.

A. Obtain an influenza vaccine annually. B. Inject insulin in the deltoid muscle. C. Administer glucagon for hyperglycemia. D. Take glyburide with breakfast.

Correct Answer is A

Explanation

Choice A rationale

Obtaining an influenza vaccine annually is crucial for individuals with type 1 diabetes to reduce the risk of infections that can exacerbate their condition.

Choice B rationale

Injecting insulin in the deltoid muscle is not standard practice as subcutaneous tissue in the abdomen or thigh is preferred for insulin absorption.

Choice C rationale

Administering glucagon is for hypoglycemia, not hyperglycemia; insulin or other medications manage hyperglycemia.

Choice D rationale

Taking glyburide is not suitable for type 1 diabetes as it requires insulin management. .

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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)

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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)