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 D
Explanation
A. "I will not be allowed to drink much liquid for 12 hours after the procedure." is incorrect. The client is usually encouraged to drink fluids after the procedure to help flush the contrast material from the body.
B. "I can expect to have some itching during the procedure." is incorrect. Itching is not a typical expectation of the myelogram procedure.
C. "I will have a radioactive substance injected during the procedure." is incorrect. A myelogram involves the injection of a contrast dye, not a radioactive substance.
D. "I will need to keep my head elevated after the procedure." is correct. Keeping the head elevated after a myelogram helps prevent headaches and other complications from the procedure.
Correct Answer is ["100"]
Explanation
- Total volume to infuse: 200 mL
- Time for infusion: 2 hours
- The IV pump rate is calculated as: (Total Volume / Time) = Rate
- So, the calculation would be: (200 mL / 2 hr) = 100 mL/hr
- The nurse should set the IV pump to deliver 100 mL/hr.
Answer= 100
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