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.

Exhibits

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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale
Providing 1,000 mL of water every 12 hours is not directly related to preventing infection or other complications post-transplant.
Choice B rationale
Keeping blood pressure equipment in the client's room helps prevent cross-contamination and infection by not sharing equipment with other clients.
Choice C rationale
A negative airflow room is used for clients with airborne infections, not for those undergoing a stem cell transplant.
Choice D rationale
Monitoring vital signs every 8 hours is insufficient; more frequent monitoring is needed post-transplant to detect complications early.

A. Encourage the client to drink cool water or sports drinks. B. Administer acetaminophen 650 mg orally. C. Start an intravenous line and infuse 0.9% saline solution. D. Encourage rest and reassess in 15 minutes.

Correct Answer is C

Explanation

Choice A rationale
Encouraging the client to drink cool water or sports drinks is appropriate for mild dehydration or heat exhaustion but not sufficient for severe heat-related illness like heat stroke, where immediate medical intervention is needed.
Choice B rationale
Administering acetaminophen 650 mg orally can help reduce fever, but it does not address the underlying issue of hyperthermia and will not provide immediate cooling needed in this emergency.
Choice C rationale
Starting an intravenous line and infusing 0.9% saline solution helps rapidly replace fluids lost through sweating and can stabilize the client's condition by rehydrating and cooling them effectively.
Choice D rationale
Encouraging rest and reassessing in 15 minutes would delay necessary medical treatment in a situation where immediate action is critical due to the severity of the client's symptoms.

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is to undergo a stem cell transplant. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

On a hot humid day, a nurse is caring for a client who is confused and presents with these vital signs: temperature 104.1°F (40.1°C), pulse 132 beats/min, respirations 26 breaths/min, and blood pressure 106/66 mmHg. What action would the nurse take to provide immediate appropriate care?

Correct Answer is C

Explanation

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