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A nurse is assessing a client who is 2 weeks postoperative following a kidney transplant. Which of the following manifestations should the nurse identify as possible organ rejection?

Weight loss

Insomnia

Temperature 36.1°C (97.0° F)

Oliguria

Answer and Explanation

The Correct Answer is D

A. Weight loss is not typically a manifestation of organ rejection post kidney transplant.

B. Insomnia is not typically associated with organ rejection post kidney transplant.

C. Normal body temperature does not indicate organ rejection post kidney transplant.

D. Oliguria or decreased urine output can be a sign of organ rejection post kidney transplant due to decreased renal perfusion.

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Correct Answer is B

Explanation

A. A urine output of 50 mL in 4 hours is inadequate and may indicate decreased renal perfusion. Magnesium sulfate can further compromise renal perfusion, so this finding warrants careful evaluation and potential adjustment of the infusion rate.
B. This indicates that the client is not experiencing respiratory depression, a potential side effect of magnesium sulfate toxicity.
C. Diminished deep tendon reflexes is an expected finding in magnesium sulfate toxicity.
D. A heart rate of 56/min is below the normal range for an adult but may be a common finding in clients receiving magnesium sulfate due to its cardiac depressant effects.

A. The client has a 5 lb weight gain since yesterday. B. Return of skin to previous position when the client's shin is palpated C. Flattened neck veins D. Oxygen saturation 93%

Correct Answer is A

Explanation

A. Sudden weight gain is a common sign of fluid overload in clients with end-stage kidney disease undergoing hemodialysis.
B. Skin turgor assessment is not as reliable in individuals with kidney disease due to changes in skin elasticity.
C. Flattened neck veins are not indicative of fluid overload; rather, they suggest dehydration.
D. Oxygen saturation may be affected by various factors but is not directly related to fluid overload in this context.

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A nurse is assessing a client who is 2 weeks postoperative following a kidney transplant. Which of the following manifestations should the nurse identify as possible organ rejection?

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