A nurse is caring for a 40-year-old client in a transplant unit.

Exhibits

The nurse is reviewing the client's assessment to prepare the client's plan of care.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential Condition:

Hypovolemia: The client shows signs of hypovolemia such as a low blood pressure (94/56 mm Hg), a high heart rate (110/min), and a relatively high urine output (1500 mL in the last hour), which may indicate an over-diuresis or inadequate fluid replacement postoperatively.

Actions to Take:

Obtain prescription for IV bolus: Administering an IV fluid bolus can help restore intravascular volume, thereby increasing blood pressure and improving perfusion to vital organs.

Lower head of bed: This action helps to increase venous return to the heart, which can help improve cardiac output and blood pressure in a hypovolemic patient.

Parameters to Monitor:

Urinary output: This is a key indicator of kidney function and fluid status. Monitoring urine output will help determine if the client is adequately responding to fluid resuscitation and maintaining appropriate kidney function.

Blood pressure: Continuous blood pressure monitoring is essential to evaluate the effectiveness of interventions aimed at correcting hypovolemia and ensuring the client's hemodynamic stability.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. This statement is incorrect because tacrolimus (an immunosuppressant) is typically required long-term to prevent organ rejection after a kidney transplant. Stopping it prematurely can lead to rejection.
B. This statement is correct because immunosuppressant drugs used after a kidney transplant often target different pathways to prevent rejection.
C. This statement is correct because acute rejection episodes may necessitate adjustments or additions to the immunosuppressive regimen.
D. This statement is correct because immunosuppressive medications increase the risk of certain cancers, so close monitoring is essential.

A. Avoid crowds. B. Take temperature weekly. C. Perform mild exercise, such as gardening. D. Eat plenty of fresh fruits and vegetables.

Correct Answer is A

Explanation

A. Neutropenic clients have reduced immune function and are at increased risk of infection from exposure to crowds and potential pathogens.
B. Taking temperatures daily, not weekly, is important to monitor for signs of infection in neutropenic clients.
C. Mild exercise is generally encouraged but should be discussed with the healthcare provider to ensure safety and infection prevention.
D. Fresh fruits and vegetables are important for overall nutrition but should be washed thoroughly to reduce the risk of infection.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse teaches patients about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions?

Correct Answer is A

Explanation

A nurse is providing teaching to a client who has neutropenia. Which of the following information should the nurse include in the teaching?

Correct Answer is A

Explanation

A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse expect for this patient?

A nurse is caring for an older adult client who has a WBC count of 2,000/mm3 after three rounds of chemotherapy. Which of the following actions should the nurse take?

A nurse is the triage officer in the emergency department when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first?

During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient has an unobstructed airway. Which action should the nurse take next?

During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next?

A nurse is caring for a client who has been exposed to an unknown chemical. Which of the following actions should the nurse take?

When requested to plan the response to the potential use of smallpox as a biological weapon, what should the emergency department (ED) nurse manager expect to obtain?

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