A nurse is evaluating a client who underwent a kidney transplant 2 weeks ago. Which of the following clinical manifestations should the nurse recognize as potential indication of organ rejection?
Temperature 36.1° C (97.0°F)
Weight loss
Hypertension
Insomnia
The Correct Answer is C
A. Temperature 36.1° C (97.0°F): A low or normal temperature is not indicative of organ rejection. Fever (≥ 38°C / 100.4°F) is a more concerning sign and may suggest rejection or infection.
B. Weight loss: Rejection often leads to fluid retention, not weight loss. Clients may actually experience weight gain due to fluid overload.
C. Hypertension: Hypertension is a key indicator of acute kidney rejection due to inflammation and impaired kidney function, leading to fluid retention and increased blood pressure. Rejection can cause renal vascular resistance and reduced urine output, leading to fluid overload and elevated blood pressure.
D. Insomnia: Insomnia is not a direct symptom of rejection. It may be due to medications like corticosteroids (e.g., prednisone), anxiety, or post-transplant stress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
A. The amount of irrigation fluid used must be added to the total output to accurately calculate fluid balance.
B. Bright red urine or large clots may indicate bleeding, which should be reported to the surgeon immediately.
C. Irrigation solution preparation does not require sterile technique; clean technique is sufficient for this task.
D. A continual need to void could be a normal post-op symptom, but if it persists or is severe, it should be investigated.
E. Ensuring the drainage tubing is patent and unobstructed is essential for proper urine flow and preventing complications.
Correct Answer is C
Explanation
A. Notify the provider: This is not the first action. The nurse should assess and attempt to resolve the issue before escalating it to the provider.
B. Irrigate the catheter: This may be required if the catheter remains obstructed, but the nurse should first assess for and address more straightforward causes like kinks.
C. Check the catheter for kinks: This is the first step because a kink or simple obstruction in the catheter tubing is a common cause of inadequate drainage. Addressing this can resolve the issue without additional interventions.
D. Adjust the rate of the bladder irrigant: The rate of irrigation is essential to prevent clots but should not be adjusted without addressing the immediate issue of no output.
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