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 ["A","B","C"]
Explanation
Choice A rationale
Immunosuppressed clients are at increased risk for infections from foodborne pathogens. Eating only cooked foods helps to kill potentially harmful bacteria, reducing the risk of infection. Raw foods can harbor bacteria and parasites that cooked foods do not.
Choice B rationale
Wearing a mask, gloves, and gown protects both the immunosuppressed client and the healthcare provider from the transmission of pathogens. This personal protective equipment (PPE) barrier reduces the likelihood of infection by preventing the transfer of pathogens.
Choice C rationale
Visitors with active infections pose a high risk to immunosuppressed clients due to their weakened immune systems. Restricting such visitors helps in minimizing the exposure to infectious agents and therefore decreases the risk of infections.
Choice D rationale
Incorrect, as disposing of linen in the trash is not a standard infection control practice. Linens should be handled according to hospital protocols, typically involving proper laundering to prevent contamination and spread of infections.
Choice E rationale
Limiting bathing is not recommended. Regular bathing helps in maintaining skin integrity and preventing skin infections. However, excessive bathing might lead to dry skin, so balanced hygiene practices should be maintained.
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A rationale
Assessing for neck vein distention helps monitor fluid overload, which is common in Cushing's syndrome due to cortisol's effects on fluid retention.
Choice B rationale
Monitoring for an irregular heart rate is important because cortisol can cause electrolyte imbalances and hypertension, which may affect heart rhythm.
Choice C rationale
Assessing blood glucose levels is essential since Cushing's syndrome can cause hyperglycemia due to cortisol's effects on glucose metabolism.
Choice D rationale
Monitoring for postural hypotension helps manage potential complications from cortisol's effects on blood pressure regulation.
Choice E rationale
Weighing the client daily is important for monitoring fluid retention and weight changes associated with Cushing's syndrome.
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