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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason : Desmopressin is a medication used to treat conditions like diabetes insipidus and certain cases of hemophilia, not allergic reactions such as hives and urticaria.
Choice B reason: Diphenhydramine is an antihistamine that is commonly used to treat allergic reactions, including hives and urticaria. It works by blocking the action of histamine, a substance in the body that causes allergic symptoms.
Choice C reason: Spironolactone is a diuretic and is not used to treat allergic reactions. It is typically prescribed for conditions like heart failure, hypertension, and certain hormonal disorders.
Choice D reason: Metoclopramide is a medication used to treat nausea and gastroparesis, not allergic reactions.
Correct Answer is B
Explanation
Choice A reason: Thyroidectomy is a surgical procedure that involves the removal of all or part of the thyroid gland. While there are risks associated with any surgery, thyroidectomy is not typically associated with fat embolism syndrome (FES). FES is more commonly linked to orthopedic procedures and trauma, particularly those involving long bones.
Choice B reason: Internal fixation of a fractured hip is a procedure that carries a risk for developing FES. FES is a serious and potentially life-threatening condition that occurs when fat globules enter the bloodstream and lodge within the blood vessels of the lungs or other organs. Hip fractures, especially those involving the long bones, can result in the release of fat globules into the bloodstream during the surgical repair process. Early surgical fixation is thought to reduce the risk of FES.
Choice C reason: Repair of a torn rotator cuff involves the shoulder joint and, while it is a significant surgical procedure, it is not typically associated with a high risk of FES. The rotator cuff is composed of muscles and tendons, and its repair does not usually involve manipulation of the long bones where fat embolism is more likely to occur.
Choice D reason: Tympanoplasty is a surgical procedure to repair a hole in the eardrum. It is an otologic procedure that does not involve the long bones or orthopedic manipulation. Therefore, it is not associated with a risk of developing FES.
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