A nurse is planning care for a client who is 12 hours postoperative following a kidney transplant. Which of the following actions should the nurse include in the plan of care?

Check the client's blood pressure every 8 hours.

Monitor for hypokalemia as a manifestation of acute rejection.

Assess urine output hourly.

Administer opioids orally.

Answer and Explanation

The Correct Answer is C

Choice A reason: Checking the client's blood pressure every 8 hours is important, but it is not as critical as monitoring urine output in the immediate postoperative period. Blood pressure should be monitored regularly, but changes in urine output can provide more immediate information about the new kidney's function.

Choice B reason: Monitoring for hypokalemia is important, as it can be a sign of acute rejection; however, hyperkalemia is more commonly associated with acute rejection due to the kidney's inability to excrete potassium. Therefore, while electrolyte monitoring is crucial, the focus is typically on hyperkalemia rather than hypokalemia.

Choice C reason: Assessing urine output hourly is essential for a client who has undergone a kidney transplant. Urine output is a direct indicator of the new kidney's function, and any significant decrease could indicate a complication such as acute rejection or obstruction.

Choice D reason: Administering opioids orally for pain management is part of postoperative care, but it is not the priority over monitoring urine output and kidney function.

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Correct Answer is B

Explanation

Choice A reason: Hypotension, or low blood pressure, is not typically associated with thyroid storm. Thyroid storm is a life-threatening condition that often presents with hypertensive crisis due to the excessive amount of thyroid hormones accelerating the body's metabolism.

Choice B reason: Increased temperature is a hallmark sign of thyroid storm. Patients experiencing a thyroid storm can have a high fever, with temperatures ranging from 104°F to 106°F. This is due to the hypermetabolic state induced by excessive thyroid hormones, which increases the body's heat production.

Choice C reason: Lethargy is not a common symptom of thyroid storm. Instead, patients may experience agitation, irritability, and anxiety due to the overstimulation of the nervous system by excessive thyroid hormones. Lethargy might be observed in hypothyroidism, which is the opposite condition.

Choice D reason: A decreased heart rate is not characteristic of thyroid storm. On the contrary, tachycardia, or a rapid heart rate, is a common symptom. The heart rate can exceed 140 beats per minute as the body's demand for oxygen increases due to the hypermetabolic state.

A. Glucose Dextrose Oral (GDO) B. Epinephrine (Adrenaline) C. Dexamethasone (Decadron) D. 0.9% Normal Saline

Correct Answer is B

Explanation

Choice A reason: Glucose Dextrose Oral (GDO) is not typically used in the immediate management of anaphylactic shock. Anaphylaxis requires rapid treatment to address severe allergic reactions and GDO does not play a role in this emergency situation.

Choice B reason: Epinephrine (Adrenaline) is the first-line treatment for anaphylactic shock. It works quickly to improve breathing, stimulate the heart, raise a dropping blood pressure, reverse hives, and reduce swelling of the face, lips, and throat.

Choice C reason: Dexamethasone (Decadron) is a corticosteroid that may be used in the treatment of anaphylaxis to reduce inflammation. However, it is not the first medication administered due to its slower onset of action compared to epinephrine.

Choice D reason: 0.9% Normal Saline is used for intravenous fluid resuscitation in anaphylactic shock but is secondary to the administration of epinephrine. It helps to maintain blood pressure and is important in the overall management but not the first medication given.

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A nurse is planning care for a client who is 12 hours postoperative following a kidney transplant. Which of the following actions should the nurse include in the plan of care?

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