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 ["A","C","E"]
Explanation
Choice A rationale
Acidosis is a key characteristic of diabetic ketoacidosis due to the accumulation of ketoacids in the body from fat metabolism.
Choice B rationale
Low blood sugar is not associated with diabetic ketoacidosis; it is characterized by hyperglycemia.
Choice C rationale
Ketosis occurs in DKA due to the breakdown of fats instead of glucose for energy, leading to an accumulation of ketones.
Choice D rationale
Fluid overload is not typical of diabetic ketoacidosis; dehydration is more common due to osmotic diuresis.
Choice E rationale
Hyperglycemia is a hallmark of diabetic ketoacidosis, resulting from the lack of insulin and the consequent high levels of glucose in the blood.
Choice F rationale
Alkalosis is not associated with diabetic ketoacidosis; the condition is defined by metabolic acidosis. .
Correct Answer is ["A","B","C"]
Explanation
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.
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