A nurse is planning care for a client who is 12 hours postoperative following a kidney transplant. Which of the following actions should the nurse include in the plan of care?

Check the client's blood pressure every 8 hours.

Monitor for hypokalemia as a manifestation of acute rejection.

Assess urine output hourly.

Administer opioids orally.

Answer and Explanation

The Correct Answer is C

Choice A reason: Checking the client's blood pressure every 8 hours is important, but it is not as critical as monitoring urine output in the immediate postoperative period. Blood pressure should be monitored regularly, but changes in urine output can provide more immediate information about the new kidney's function.

Choice B reason: Monitoring for hypokalemia is important, as it can be a sign of acute rejection; however, hyperkalemia is more commonly associated with acute rejection due to the kidney's inability to excrete potassium. Therefore, while electrolyte monitoring is crucial, the focus is typically on hyperkalemia rather than hypokalemia.

Choice C reason: Assessing urine output hourly is essential for a client who has undergone a kidney transplant. Urine output is a direct indicator of the new kidney's function, and any significant decrease could indicate a complication such as acute rejection or obstruction.

Choice D reason: Administering opioids orally for pain management is part of postoperative care, but it is not the priority over monitoring urine output and kidney function.

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Correct Answer is C

Explanation

Choice A reason: Constipation can be a side effect of many cancer treatments, including radiation therapy. However, it is not commonly associated with targeted radiation therapy to the neck. Constipation is more often related to opioid pain medications, decreased physical activity, or dietary changes that a patient may experience during cancer treatment.

Choice B reason: Decreased tear production is not a typical side effect of targeted radiation therapy to the neck. This condition, known as dry eye syndrome, is more commonly associated with radiation therapy that affects the eye or orbital area directly.

Choice C reason: Mouth ulcers, also known as mucositis, are a common adverse effect of radiation therapy to the neck. Radiation can damage the mucosal lining of the mouth, leading to painful sores that can affect a patient's ability to eat, speak, and swallow. These ulcers typically develop one to two weeks after starting treatment and may persist for some time after the treatment ends.

Choice D reason: Peripheral neuropathy, which involves damage to the peripheral nerves and often results in symptoms like numbness, tingling, or pain in the hands and feet, is not a common side effect of radiation therapy to the neck. It is more frequently associated with certain chemotherapeutic agents or radiation therapy to areas of the body where peripheral nerves are located.

A. Decreased urinary output B. Emesis of 250 mL C. Decreased anxiety D. Increased respiratory rate to 26/min

Correct Answer is C

Explanation

Choice A reason: Decreased urinary output is not a direct indicator of morphine's effectiveness in acute heart failure. While morphine can lead to urinary retention, this is generally considered a side effect rather than an intended therapeutic outcome.

Choice B reason: Emesis, or vomiting, of 250 mL is not an indication of morphine's effectiveness. In fact, nausea and vomiting are common side effects of morphine and other opioids. If emesis occurs, it may necessitate further intervention.

Choice C reason: Decreased anxiety is a sign that the morphine is effective. Morphine has anxiolytic properties, meaning it can help alleviate anxiety, which is beneficial in acute heart failure where anxiety can exacerbate symptoms like shortness of breath.

Choice D reason: An increased respiratory rate to 26/min is not an indication of morphine's effectiveness and is a cause for concern. Morphine can depress the respiratory system, and an increased respiratory rate may indicate compensation for hypoxemia or the onset of adverse effects.

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A nurse is planning care for a client who is 12 hours postoperative following a kidney transplant. Which of the following actions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is receiving targeted radiation therapy to the neck. The nurse should plan to monitor the client for which of the following as an adverse effect of this therapy?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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