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 D
Explanation
Choice A rationale
Joint pain in hands and knees is a common symptom of SLE due to inflammation but is not immediately life-threatening. It requires management but is not the highest priority.
Choice B rationale
A dry, raised rash on the face, such as a malar rash, is common in SLE and should be monitored and treated, but it is not immediately life-threatening.
Choice C rationale
Feelings of depression are serious and need addressing but are not an immediate threat to physical health. Depression is often associated with chronic illnesses and requires comprehensive mental health support.
Choice D rationale
Presence of peripheral edema could indicate renal involvement or cardiac issues in SLE, which can be life-threatening. It is crucial to address this finding urgently to prevent complications such as renal failure or severe cardiovascular events.
Correct Answer is A
Explanation
Choice A rationale
A raised rash across the nose and face, known as a butterfly rash, is a classic and distinctive manifestation of systemic lupus erythematosus (SLE), often exacerbated by sunlight exposure.
Choice B rationale
Hypothermia is not a common manifestation of SLE; patients more frequently experience fevers due to inflammation and immune system dysregulation.
Choice C rationale
Weight gain is not a typical direct manifestation of SLE; patients might experience weight changes due to medications or complications but not as a primary symptom.
Choice D rationale
Muscle hyperreflexia is not associated with SLE; neurological symptoms in SLE might include seizures or cognitive dysfunction, but not hyperreflexia.
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