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.
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Monitoring for fluid volume excess is not typically a concern for children with Addison's disease, as they are more prone to fluid volume deficit due to adrenal insufficiency.
Choice B rationale
Placing the child on a low-sodium diet is inappropriate for Addison's disease, as these patients often need increased sodium intake due to their impaired ability to retain sodium.
Choice C rationale
Teaching the parents about cortisol replacement therapy is crucial in managing Addison's disease, as the condition involves adrenal insufficiency requiring hormone replacement to manage symptoms and prevent adrenal crisis.
Choice D rationale
Discussing the manifestations of hyperglycemia is not relevant, as Addison's disease is more commonly associated with hypoglycemia due to reduced cortisol production.
Correct Answer is B
Explanation
Choice A rationale
Hyperactive deep tendon reflexes are not associated with thrombocytopenia (low platelet count). Thrombocytopenia primarily affects bleeding and clotting functions rather than neuromuscular reflexes.
Choice B rationale
Spontaneous bleeding is a significant risk with a platelet count of 9,000/mm³, which is critically low. Platelets are essential for blood clotting, and severe thrombocytopenia increases the risk of spontaneous bleeding.
Choice C rationale
Oliguria, or decreased urine output, is not directly related to thrombocytopenia. It may be associated with kidney function issues, but it is not a consequence of low platelet counts.
Choice D rationale
Infection is not directly related to a low platelet count. While patients with severe thrombocytopenia may be at risk for bleeding complications, their susceptibility to infections is more related to their white blood cell counts and immune function.
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