A nurse is caring for a 65-year-old male client who is admitted to the emergency department for fatigue.
Which of the following findings indicate that the client may be experiencing transplant rejection? (Select all that apply)
Assessment of incision site
Assessment of lower extremities
Blood pressure
Sodium level
Correct Answer : A,B,C
Choice A rationale:
Tenderness, redness, and swelling at the incision site can indicate an infection or transplant rejection, both of which require immediate medical attention to prevent further complications.
Choice B rationale:
Swelling in the lower extremities (edema) can be a sign of fluid retention, which may indicate kidney dysfunction or transplant rejection, necessitating prompt evaluation and intervention.
Choice C rationale:
Elevated blood pressure (180/90 mm Hg) can be a sign of transplant rejection, as the body may be responding to the new organ as a foreign object, leading to increased blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
Choice A rationale
Hypertension is not a typical manifestation of sepsis; sepsis usually involves hypotension.
Choice B rationale
Hypoglycemia is not a common manifestation of sepsis; hyperglycemia is more typical.
Choice C rationale
Altered mental status can occur due to the systemic inflammation and infection affecting the brain.
Choice D rationale
An elevated WBC count indicates an immune response to infection, which is a common sign of sepsis.
Choice E rationale
Vomiting can occur due to the body's response to the infection and systemic inflammation.
Correct Answer is D
Explanation
Choice A rationale
High-protein and high-carbohydrate foods are beneficial, but they do not directly address the immediate respiratory issues in ARDS.
Choice B rationale
Encouraging oral intake of fluids may not be appropriate as it can contribute to fluid overload and worsen pulmonary edema in ARDS patients.
Choice C rationale
Administering low-flow oxygen might be necessary but isn't the most crucial intervention for ARDS. High-flow oxygen or mechanical ventilation is typically required.
Choice D rationale
Placing the client in a prone position has been shown to improve oxygenation in ARDS by enhancing lung expansion and ventilation-perfusion matching.
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