A nurse is caring for a female client, 45 years old, with a kidney transplant, who is admitted to the emergency department for fatigue. The client is receiving oxygen via a 2L nasal cannula.

Exhibits

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

Sodium level

Creatinine level

Blood pressure

Assessment of lower extremities

Answer and Explanation

The Correct Answer is B

Choice A:
Sodium level - Sodium levels within the normal range do not indicate transplant rejection.
Choice B:
Creatinine level - Elevated creatinine levels suggest impaired kidney function, which can be a sign of kidney transplant rejection.
Choice C:
Blood pressure - While high blood pressure can be associated with kidney issues, it is not a direct indicator of transplant rejection.
Choice D:
Assessment of lower extremities - No visible edema or redness around the transplant site does not indicate rejection.

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Correct Answer is C

Explanation

Choice A rationale
Encouraging the client to drink cool water or sports drinks is appropriate for mild dehydration or heat exhaustion but not sufficient for severe heat-related illness like heat stroke, where immediate medical intervention is needed.
Choice B rationale
Administering acetaminophen 650 mg orally can help reduce fever, but it does not address the underlying issue of hyperthermia and will not provide immediate cooling needed in this emergency.
Choice C rationale
Starting an intravenous line and infusing 0.9% saline solution helps rapidly replace fluids lost through sweating and can stabilize the client's condition by rehydrating and cooling them effectively.
Choice D rationale
Encouraging rest and reassessing in 15 minutes would delay necessary medical treatment in a situation where immediate action is critical due to the severity of the client's symptoms.

A. Insert an indwelling catheter to monitor sediment in the urine. B. Provide the client with fresh fruit to avoid constipation. C. Take the client's temperature once per shift. D. Limit the number of health care workers entering the room.

Correct Answer is D

Explanation

Choice A rationale
Inserting an indwelling catheter is not recommended for immunosuppressed clients due to the increased risk of infection. Minimizing invasive procedures is critical in these patients.
Choice B rationale
Providing fresh fruit is not advisable for immunosuppressed clients, as raw fruits and vegetables can harbor bacteria and increase the risk of infection. Cooked foods are safer options.
Choice C rationale
Taking the client's temperature once per shift is insufficient for monitoring infection in immunosuppressed clients. More frequent temperature monitoring is necessary to detect early signs of infection.
Choice D rationale
Limiting the number of health care workers entering the room is essential for reducing the risk of infections in immunosuppressed clients, as it minimizes exposure to potential pathogens.

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Naxlex Comprehensive Predictor Exams

On a hot humid day, a nurse is caring for a client who is confused and presents with these vital signs: temperature 104.1°F (40.1°C), pulse 132 beats/min, respirations 26 breaths/min, and blood pressure 106/66 mmHg. What action would the nurse take to provide immediate appropriate care?

Correct Answer is C

Explanation

A nurse is planning care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is D

Explanation

A nurse is reviewing the laboratory results of a client who was admitted with metastatic bone cancer. The nurse should expect to find an increase in which of the following laboratory values?

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