A nurse is caring for a female client, 45 years old, with a kidney transplant, who is admitted to the emergency department for fatigue. The client is receiving oxygen via a 2L nasal cannula.
Which of the following findings indicate that the client may be experiencing transplant rejection? (Select all that apply)
Sodium level
Creatinine level
Blood pressure
Assessment of lower extremities
The Correct Answer is B
Choice A:
Sodium level - Sodium levels within the normal range do not indicate transplant rejection.
Choice B:
Creatinine level - Elevated creatinine levels suggest impaired kidney function, which can be a sign of kidney transplant rejection.
Choice C:
Blood pressure - While high blood pressure can be associated with kidney issues, it is not a direct indicator of transplant rejection.
Choice D:
Assessment of lower extremities - No visible edema or redness around the transplant site does not indicate rejection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
DIC is not controllable with lifelong heparin usage. Heparin may be used to manage DIC, but it is not a permanent solution, and the underlying cause of DIC must be addressed.
Choice B rationale
DIC is caused by abnormal coagulation involving fibrinogen. It is characterized by widespread activation of the clotting cascade, leading to both clot formation and bleeding due to consumption of clotting factors and platelets.
Choice C rationale
DIC is not a genetic disorder involving a vitamin K deficiency. It is an acquired condition resulting from severe illnesses or injuries that trigger abnormal clotting and bleeding processes.
Choice D rationale
DIC is not characterized by an elevated platelet count. Instead, it involves thrombocytopenia due to the consumption of platelets in widespread clotting, leading to a decreased platelet count.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale: Contact precautions are not necessary in this situation as the client is presenting symptoms of a possible infection related to chemotherapy-induced immunosuppression, not a contagious disease.
Choice B rationale: Placing the client in a private room is crucial to protect her from potential infections, given her compromised immune system due to chemotherapy.
Choice C rationale: Encouraging the client to increase fluid intake can help manage fever and muscle aches and keep her hydrated, which is important when dealing with symptoms of infection and fatigue.
Choice D rationale: Wearing a mask when caring for the client is necessary to protect both the client and the healthcare provider from potential infections, considering the client’s immunocompromised state.
Choice E rationale: Preparing to administer an antibiotic should be based on the healthcare provider's orders and further diagnostic results. While it might be necessary, it is not an immediate nursing action without provider confirmation.
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