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: Instructing the client to avoid eating raw vegetables may be a precautionary measure due to potential immunosuppression from AIDS, but it does not directly demonstrate advocacy. Advocacy would involve actions that support the client's rights, choices, and interests, and while dietary advice is important, it is not an advocacy action in itself.
Choice B reason: Initiating a referral for the client to a home health agency is a clear demonstration of client advocacy. This action shows that the nurse is taking steps to ensure the client receives the necessary support to manage their condition at home, respecting their wish to maintain independence and quality of life.
Choice C reason: Reminding the client of the importance of medication adherence is part of the nurse's educational role but does not necessarily reflect advocacy. Advocacy would involve more proactive measures to support the client's treatment and care decisions.
Choice D reason: Telling the client to avoid places where there are large crowds of people is good advice to reduce the risk of infections, but it is not an advocacy action. Advocacy involves representing the client's interests and facilitating their choices and access to care.
Correct Answer is A
Explanation
Choice A reason: White rice is considered a low-potassium food, making it a suitable option for someone with chronic kidney disease who needs to limit their potassium intake. One cup of cooked white rice contains approximately 54 mg of potassium, which is significantly lower than the other options listed.
Choice B reason: Nonfat yogurt can vary in potassium content, but on average, a 1/2 cup serving may contain around 200 to 300 mg of potassium. While it is a nutritious choice, it contains more potassium than white rice and should be consumed in moderation by individuals with potassium restrictions.
Choice C reason: A medium baked potato with skin is high in potassium, with one potato containing over 900 mg of potassium. This makes it an unsuitable choice for someone who needs to limit their potassium intake due to chronic kidney disease.
Choice D reason: Peanut butter contains a moderate amount of potassium. Two tablespoons of peanut butter can have around 150 to 200 mg of potassium. Although it's not as high in potassium as a baked potato, it still contains more potassium than white rice.
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