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.

Answer and Explanation

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.

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Free Nursing Study Resources

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.

A. Advise the client that the healthcare provider (HCP) needs to be made aware of the current diet. B. Suggest that the client replace the leafy vegetables with a protein source such as nuts or beans. C. Confirm that the clients diet choices will help the medication be more effective in preventing blood clots. D. Commend the client for a healthy lifestyle and encourage the client to continue current diet habits.

Correct Answer is A

Explanation

A. Advise the client that the healthcare provider (HCP) needs to be made aware of the current diet: Green leafy vegetables are high in vitamin K, which can interfere with the effectiveness of warfarin by promoting clotting. The healthcare provider must be informed to adjust the medication dose if necessary or provide specific dietary guidance.

B. Suggest that the client replace the leafy vegetables with a protein source such as nuts or beans: Advising the client to eliminate green vegetables is not appropriate because sudden changes in vitamin K intake can destabilize warfarin therapy. Consistency in vitamin K consumption is key rather than abrupt dietary changes.

C. Confirm that the client's diet choices will help the medication be more effective in preventing blood clots: Regular consumption of vitamin K-rich foods without dose adjustment can decrease warfarin's anticoagulant effect, increasing the risk of clot formation. The current diet does not inherently support the intended action of the medication.

D. Commend the client for a healthy lifestyle and encourage the client to continue current diet habits: Although a diet rich in vegetables is generally healthy, with warfarin therapy, any vitamin K intake must be consistent and properly managed. Simply encouraging the client without notifying the provider could lead to therapeutic failure.

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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?

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After taking orlistat for one week, a female client tells the home health nurse that she is experiencing increasingly frequent oily stools and flatus. Which action should the nurse take?

Correct Answer is A

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A client who is a vegetarian has a new prescription for warfarin. The client reports eating green leafy vegetables every day. How should the nurse respond?

Correct Answer is A

Explanation

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