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 B
Explanation
A. Obtain a cardiology consult is not an immediate action for an irregular heart rate during suctioning; it is a more long-term consideration.
B. Perform pre-oxygenation prior to suctioning is the correct action to prevent hypoxia, which can cause increased heart rate and irregular rhythms during suctioning.
C. Administer an antidysrhythmic medication is not appropriate for the immediate concern of heart rate changes during suctioning.
D. Suction the client less frequently does not address the acute problem of the irregular heart rate; pre-oxygenation before suctioning is more relevant.
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