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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Free Nursing Study Resources

Correct Answer is ["A","B","C","D","E"]

Explanation

Choice A rationale
Assessing for neck vein distention helps monitor fluid overload, which is common in Cushing's syndrome due to cortisol's effects on fluid retention.
Choice B rationale
Monitoring for an irregular heart rate is important because cortisol can cause electrolyte imbalances and hypertension, which may affect heart rhythm.
Choice C rationale
Assessing blood glucose levels is essential since Cushing's syndrome can cause hyperglycemia due to cortisol's effects on glucose metabolism.
Choice D rationale
Monitoring for postural hypotension helps manage potential complications from cortisol's effects on blood pressure regulation.
Choice E rationale
Weighing the client daily is important for monitoring fluid retention and weight changes associated with Cushing's syndrome.

A. Monitor the client’s hydration status. B. Encourage the client to engage in physical activities. C. Administer medications as prescribed. D. Educate the client on dietary needs.

Correct Answer is A

Explanation

Choice A rationale
Monitoring the client’s hydration status is critical for older adults, especially those on a medical-surgical unit, to prevent dehydration, which can lead to serious complications such as renal impairment, confusion, and electrolyte imbalance.
Choice B rationale
Encouraging physical activities is beneficial but is not always feasible or safe for all older clients, especially those with certain medical conditions or mobility limitations.
Choice C rationale
Administering medications as prescribed is essential but is a standard practice for all clients and not specific to older adults' unique needs.
Choice D rationale
Educating the client on dietary needs is important but secondary to monitoring hydration, which addresses more immediate physiological needs and complications.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has Cushing's syndrome.Which of the following interventions should the nurse expect to perform? (Select all that apply.)

Correct Answer is ["A","B","C","D","E"]

Explanation

A nurse is caring for an older client on a medical-surgical unit.Which of the following interventions should be included in the plan of care?

Correct Answer is A

Explanation

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