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A nurse is caring for a client who is admitted to the emergency department for fatigue.

Exhibits

Which of the following findings indicate that the client may be experiencing transplant rejection? (Select all that apply).

Assessment of lower extremities

Sodium level

Lung sounds

Creatinine level

Assessment of Incision site

Bowel sounds

Blood pressure.

Answer and Explanation

Correct Answer : D,E

A. Assessment of Lower Extremities
Edema is common in renal failure but not specific to transplant rejection.

B. Sodium Level
Sodium level changes can occur with various conditions but are not specific to transplant rejection.

C. Lung Sounds
Lung sounds are important for respiratory issues but not directly indicative of kidney transplant rejection.
D. Creatinine Level
Elevated creatinine indicates possible kidney dysfunction or rejection.

E. Assessment of Incision Site
Signs of infection or inflammation at the incision site could indicate transplant issues.

F. Bowel Sounds
Hypoactive bowel sounds are related to gastrointestinal issues, not directly to transplant rejection.

G. Blood Pressure
Elevated blood pressure can be a consequence of many conditions but is not specific for transplant rejection.

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Correct Answer is D

Explanation

A. Nasal congestion is not a primary sign of autonomic dysreflexia, though it can be a symptom of other conditions.

B. A severe headache can be a symptom of autonomic dysreflexia but is not the sole indicator of the condition.

C. Elevated blood pressure can be a result of autonomic dysreflexia but is not necessarily an indication of risk without other symptoms.

D. A distended bladder is a common trigger for autonomic dysreflexia in clients with a spinal cord injury at or above T-6, making it a key indicator for monitoring.

A. Measure the circumference of the thigh. B. Palpate the femoral pulse. C. Instruct the client to wiggle his toes. D. Monitor the client's calf for edema.

Correct Answer is C

Explanation

A. Measuring the circumference of the thigh can help assess for swelling but is not specific for neurovascular assessment.
B. Palpating the femoral pulse is not as relevant for assessing neurovascular status at the site of a femur fracture; instead, the focus is on more distal pulses and sensations.
C. Instructing the client to wiggle his toes assesses motor function and circulation to the distal extremities, which are crucial for neurovascular status.
D. Monitoring the calf for edema is not the primary method for assessing neurovascular status at the site of a femur fracture; it’s more relevant for assessing for deep vein thrombosis.

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A nurse is caring for a client who is admitted to the emergency department for fatigue. Exhibits Which of the following findings indicate that the client may be experiencing transplant rejection? (Select all that apply).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?

Correct Answer is D

Explanation

A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status?

Correct Answer is C

Explanation

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A nurse is caring for a client who is admitted to the emergency department for fatigue.

Exhibits

Which of the following findings indicate that the client may be experiencing transplant rejection? (Select all that apply).