A client who had a kidney transplant last week is receiving cyclosporine. This morning the client reports experiencing a headache and blurred vision. Based on which assessment finding should the nurse withhold the medication until the healthcare provider (HCP) is notified?
Temperature of 100.8° F (38.2° C).
Elevated blood urea nitrogen (BUN).
Renal output of 120 mL/hour.
Blood pressure 180/98 mm Hg.
The Correct Answer is D
A. Temperature of 100.8° F (38.2° C): A mildly elevated temperature in a post-transplant client may suggest infection or early rejection, both of which warrant monitoring. However, this is not a direct reason to withhold cyclosporine, which is essential for preventing organ rejection.
B. Elevated blood urea nitrogen (BUN): Elevated BUN could indicate impaired renal function, which should be monitored during cyclosporine therapy. However, this alone is not an urgent reason to withhold the medication without further evaluation of kidney function trends and symptoms.
C. Renal output of 120 mL/hour: This is a healthy urine output and suggests good renal perfusion and function. It does not present any contraindication to continuing cyclosporine and supports that the transplanted kidney is functioning well.
D. Blood pressure 180/98 mm Hg: Hypertension is a known side effect of cyclosporine and can become severe. A blood pressure this high, especially when accompanied by headache and blurred vision, suggests possible cyclosporine-induced hypertensive crisis or toxicity, and warrants immediate withholding of the medication and notification of the HCP.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Ask the client to describe her dietary intake history for the last several days: Orlistat works by inhibiting fat absorption, and excessive intake of dietary fats can cause oily stools and gas. Assessing the client’s recent diet helps determine if her symptoms are due to high fat consumption, which can then be managed through dietary adjustments.
B. Instruct the client to increase her intake of saturated fats over the next week: Increasing fat intake would likely worsen her symptoms, as orlistat prevents fat absorption, leading to more pronounced gastrointestinal side effects if fat intake remains high.
C. Advise the client to stop taking the drug and contact her healthcare provider (HCP): Stopping orlistat is unnecessary at this stage. Oily stools are a common and expected side effect if dietary fat intake is not controlled, so addressing dietary habits is the first and more appropriate intervention.
D. Obtain a stool specimen to evaluate for occult blood and fat content: There is no indication that the client’s symptoms suggest gastrointestinal bleeding. The oily stools are an anticipated effect of fat malabsorption caused by orlistat, not a sign of occult blood loss.
Correct Answer is A
Explanation
A. Acetaminophen: Acetaminophen is metabolized by the liver, and excessive or chronic use can lead to hepatotoxicity, which presents with signs such as jaundice. Observing jaundice in a client taking acetaminophen requires prompt notification of the healthcare provider to assess for potential liver damage.
B. Prednisone: Prednisone can have many systemic effects, including fluid retention and immune suppression, but it is not typically associated with liver toxicity or jaundice as a primary adverse effect.
C. Captopril: Captopril is used to manage hypertension and can cause renal dysfunction, but it is not commonly linked to liver dysfunction or jaundice. Liver-related side effects are rare with ACE inhibitors.
D. Omeprazole: Omeprazole is a proton pump inhibitor used for gastroesophageal reflux and has minimal hepatic side effects. It is not commonly associated with jaundice in clinical practice.
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