A nurse is caring for a 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 lower extremities
Sodium level
Lung sounds
Creatinine level
Assessment of Incision site
Bowel sounds
Blood pressure.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Atelectasis is incorrect. Atelectasis refers to lung collapse, which presents as reduced breath sounds and hypoxemia, not abnormal chest movement during respiration.
B. Flail chest is correct. Flail chest is characterized by paradoxical chest movement where a segment of the chest wall moves inward during inspiration and outward during expiration.
C. Pneumothorax is incorrect. Pneumothorax would cause sudden chest pain and dyspnea, but does not cause paradoxical chest movement.
D. Hemothorax is incorrect. Hemothorax involves blood in the pleural space and would cause reduced breath sounds and signs of shock, but not paradoxical chest movement.
Correct Answer is D
Explanation
A. "Wear an eye patch on the right eye at all times.": This is not appropriate as wearing an eye patch continuously can cause strain on the other eye. It is generally recommended to alternate the eye patch between eyes to manage diplopia (double vision).
B. "Plan to relax in a hot tub spa each day.": This is inappropriate as heat can exacerbate MS symptoms, leading to increased fatigue and other symptoms.
C. "Engage in a vigorous exercise program.": This is inappropriate because vigorous exercise can cause excessive fatigue in individuals with MS. A moderate, well-balanced exercise program is more beneficial.
D. "Implement a schedule to include periods of rest.": This is appropriate as incorporating periods of rest helps manage fatigue, which is a common symptom in MS. It allows the client to balance activity and rest to avoid exacerbation of symptoms.
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