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

Administer opioids PO.

Monitor for hypokalemia as a manifestation of acute rejection.

Assess urine output hourly.

Check the client's blood pressure every 8 hr.

Answer and Explanation

The Correct Answer is C

C. Monitoring urine output is crucial in the early postoperative period after a kidney transplant to assess kidney function and ensure adequate perfusion.

A Managing pain is important, but the administration of opioids should be carefully considered due to their potential to mask symptoms and side effects that could be critical in the postoperative period.

B. While electrolyte imbalances are important to monitor, hypokalemia specifically is not typically associated with acute rejection in the early postoperative period.

D. Blood pressure monitoring every 8 hours may not be sufficient in the immediate postoperative period, especially given the potential for fluid shifts and changes in hemodynamic status.

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Correct Answer is C

Explanation

C. Heat therapy can help relax muscles and relieve stiffness in the joints, making it easier to move around and start the day.

A While it's important to maintain a regular sleep schedule, short naps may actually help manage fatigue associated with the condition

B. Cold therapy, such as using ice packs, can actually help reduce inflammation and relieve pain in inflamed joints for many individuals with RA.

D. Decreasing the amount of iron in the diet is not advisable without specific medical guidance.

A. Raise the drainage system to the client's chest level. B. Clamp the tubing to check for air leaks. C. Empty the collection chamber. D. Gently squeeze the tubing to remove excess drainage.

Correct Answer is B

Explanation

B. The appropriate action for a nurse to take would be to check for air leaks in the system. This can be done by clamping the tubing momentarily to see if the bubbling stops, which would suggest the presence of a leak.

A The drainage system should always be kept below the level of the chest and should not be raised or emptied unless specifically indicated.

C. Emptying the collection chamber is typically unnecessary unless it is nearing full capacity. Continuous bubbling in the water seal chamber does not indicate that the collection chamber needs immediate emptying.

D. Squeezing the tubing can disrupt the functioning of the drainage system and is not recommended. Drainage should flow passively into the collection chamber without external manipulation.

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

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