A nurse is caring for a client who has end-stage liver disease and is being placed on a transplant list. Which of the following statements by the client is the priority for the nurse to report to the provider?
"My parent has type 2 diabetes mellitus."
"I wish my family was more supportive of my decision."
"I am not very good about taking prescribed medication."
"I had symptoms of asthma when I was a child."
The Correct Answer is C
C. This is crucial because good medication adherence is essential for a transplant recipient to prevent rejection and maintain overall health. Non-adherence can jeopardize the transplant's success.
A This could be a risk factor for the client's own health, but it's not directly related to the transplant process or medication adherence.
B. This highlights a psychosocial concern, important for overall well-being, but doesn't directly impact the transplant candidacy.
D. This might be relevant for the medical history, but it doesn't directly affect medication adherence or the immediate transplant candidacy (unless the asthma is severe and uncontrolled).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
The nurse should administer a total 1320ml sodium chloride in the first hour, 880ml each subsequent hour.
Rationale
First Hour Administration
Rate: 15 ml/kg/hr Client's weight: 88 kg
Calculation: 15 ml/kg/hr × 88 kg= 1320ml/hr
Therefore, in the first hour, the nurse should administer 1320 mL of 0.9% sodium chloride.
Subsequent Hour Administration
Rate: 10 ml/kg/hr Client's weight: 88 kg
Calculation: 10 ml/kg/hr × 88kg= 880mls
Therefore, each subsequent hour after the first, the nurse should administer 880 mL of 0.9% sodium chloride.
Correct Answer is D
Explanation
D. Edema is expected in the initial hours and days following major burns and can be particularly pronounced in full-thickness burns due to extensive tissue damage and inflammation.
A Initially, full-thickness burns may not be as painful due to nerve damage; however, surrounding areas with partial-thickness burns or areas where nerve endings are intact can be extremely painful. The absence of severe pain at the site of full-thickness burns is common initially due to nerve damage, but pain management is crucial as inflammation progresses.
B. Full-thickness burns typically involve destruction of the entire epidermis and dermis, leading to the absence of blisters. Blisters are characteristic of partial-thickness burns, where the epidermis is partially damaged but not completely destroyed.
C. Epithelialization refers to the process of new skin cells migrating and covering the wound, a process that occurs during the later stages of wound healing. In the acute phase of full-thickness burns, epithelialization does not occur because the skin layers are completely destroyed. This process starts later once the wound has been adequately debrided and begins to heal.
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