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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Correct Answer is ["A","B","D"]

Explanation

A. Review most recent coagulation laboratory values: Checking coagulation studies like INR, PT, or aPTT is essential to assess the client's bleeding risk and determine if the anticoagulant effect is too strong, helping guide further medical management.

B. Report findings to healthcare provider (HCP): Bleeding gums and easy bruising are signs of excessive anticoagulation, which could become life-threatening. Promptly notifying the HCP allows for immediate evaluation and possible adjustment of the medication.

C. Complete a medication variance report: A medication variance report is appropriate when there is an error in prescribing, dispensing, or administering. Since this appears to be a medication side effect rather than an error, a variance report is not needed at this stage.

D. Obtain a soft bristle toothbrush for client: Using a soft toothbrush minimizes trauma to the gums, helping to reduce the risk of further bleeding while still maintaining oral hygiene, an important supportive intervention for clients on anticoagulants.

E. Provide a PRN nonsteroidal antiinflammatory drug (NSAID) for gum discomfort: NSAIDs increase the risk of bleeding and should be avoided in clients taking anticoagulants. Treating discomfort with NSAIDs could worsen bleeding complications rather than relieve them safely.

A. May stop taking medication if no symptoms of GI discomfort. B. Explain that pantoprazole may be taken with or without food. C. Teach the client about risk of developing a Curling's ulcer. D. Discuss the risk of gastric bleeding related to severe burns. E. Tell how pantoprazole effectively heals ulcers.

Correct Answer is ["B","C","D"]

Explanation

A. May stop taking medication if no symptoms of GI discomfort: Pantoprazole is prescribed prophylactically in burn clients to prevent stress ulcers, not just to treat existing symptoms. Stopping it without medical advice could increase the risk of serious complications like gastric bleeding.

B. Explain that pantoprazole may be taken with or without food: Pantoprazole, a proton pump inhibitor (PPI), can be taken without regard to meals. Educating the client on flexible timing improves adherence and reduces confusion about the medication regimen.

C. Teach the client about risk of developing a Curling's ulcer: Severe burns increase the risk of Curling’s ulcer, a stress-related gastric ulcer. Explaining this risk helps the client understand the preventative role of pantoprazole in their overall care plan.

D. Discuss the risk of gastric bleeding related to severe burns: Gastric bleeding is a serious, potentially life-threatening complication associated with stress ulcers in burn patients. Teaching the client about this risk provides a clear rationale for continuing pantoprazole therapy.

E. Tell how pantoprazole effectively heals ulcers: While pantoprazole can treat ulcers, in this case it is prescribed to prevent ulcer formation rather than to heal an existing ulcer. The teaching should focus on prevention, not healing.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After receiving the third dose of a new oral anticoagulant prescription, an older adult client develops bleeding and tender gums and has many new bruises. Which action(s) should the nurse implement? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

The healthcare provider (HCP) prescribes pantoprazole for a client who experienced partial and full thickness burns. The client is questioning the nurse if this medication is necessary. Which action(s) should the nurse implement? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

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