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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Telling a family to limit discussing past events with the client may not be culturally sensitive. Each culture has its own views on reminiscing and sharing memories, especially during end-of-life care. Some cultures value the sharing of stories and memories as a way to honor the individual's life.
Choice B reason: Saying "We will respect what is important to you" is a statement that acknowledges and incorporates the client's and family's cultural beliefs. It shows a willingness to understand and prioritize their values, customs, and preferences in the care plan. This approach is aligned with culturally competent care, which is crucial in hospice settings.
Choice C reason: Offering to arrange all burial services may overstep boundaries, as burial practices are deeply rooted in cultural and religious beliefs. It is important for healthcare providers to discuss and understand the family's wishes and provide support in accordance with their specific cultural practices.
Choice D reason: Advising that grieving should not be done in front of the client may not align with the family's cultural beliefs about expressing emotions and grief. Different cultures have varied expressions of grief, and it is essential to respect these practices. Some cultures view the open expression of grief as an important part of the mourning process.

Correct Answer is C
Explanation
Choice A reason: Injecting the medication into the abdomen above the level of the iliac crest is not recommended. The preferred sites for subcutaneous injections are the fatty tissue over the triceps, the abdomen from below the costal margin to the iliac crests, and the anterior aspects of the thighs. The area above the iliac crest may not have sufficient subcutaneous tissue, which could affect the absorption of the medication.
Choice B reason: Using a 1-inch needle can be appropriate depending on the client's body mass. For most adults, a 5/8-inch to 1-inch needle is recommended for subcutaneous injections to ensure the medication is delivered to the subcutaneous tissue and not into the muscle.
Choice C reason: Using a 25-gauge needle is the appropriate action when administering heparin subcutaneously. A smaller gauge needle, such as 25-gauge, is typically used for subcutaneous injections to minimize discomfort and tissue trauma.
Choice D reason: Massaging the injection site after administration of the medication is not recommended when administering heparin subcutaneously. Massaging the site can cause the medication to be absorbed more quickly than intended and may increase the risk of bleeding.
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