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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 B

Explanation

A. The visibility of the eyelets on the chest tube is not a critical indicator for immediate notification unless other issues are present.
B. Movement of the trachea toward the unaffected side can indicate tension pneumothorax or other significant issues requiring immediate intervention.
C. Crepitus around the insertion site can indicate subcutaneous emphysema, which may be a complication but not an immediate emergency.
D. Bubbling in the water seal chamber during exhalation is a normal finding, as it indicates that the chest tube is functioning to allow air to escape.

A. Learn to control impulsive behavior. B. Establish the ability to communicate effectively. C. Compensate for loss of depth perception. D. Improve left-side motor function.

Correct Answer is B

Explanation

A. Learning to control impulsive behavior is more relevant for a right hemispheric CVA, which affects impulse control and judgment.

B. Establishing the ability to communicate effectively is crucial for a left hemispheric CVA, which often affects language and speech functions.

C. Compensating for loss of depth perception is related to right hemispheric CVA, which affects spatial awareness and perception.

D. Improving left-side motor function is important but secondary to addressing communication issues in a left hemispheric CVA where language deficits are a priority.

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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

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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).