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: The client's effort to protect their skin due to increased fragility is a normal part of the aging process. As the skin ages, it becomes thinner and less elastic, making it more susceptible to injuries. The client's proactive approach to skin care is appropriate and does not indicate a need for follow-up.
Choice B reason: The statement "I guess feeling down is just part of aging" suggests a possible misconception about mental health and aging. While it's true that older adults may face various challenges that can affect their mood, persistent feelings of sadness or depression are not a normal part of aging and should be addressed. Mental health is as important as physical health, and feeling down can be a sign of depression, which is treatable at any age.
Choice C reason: Concerns about changes in appearance, such as hair thinning, are common as people age. The client's plan to visit a wig shop indicates they are taking steps to manage these changes and maintain their self-esteem. This does not necessarily indicate a need for follow-up unless the hair loss is sudden or accompanied by other symptoms that could suggest an underlying health issue.
Choice D reason: Missing an appointment but taking the initiative to reschedule shows that the client is actively managing their health care. Regular eye exams are important for older adults as they can help detect vision changes and conditions like glaucoma or cataracts early on. This behavior is responsible and does not indicate a need for follow-up.
Correct Answer is D
Explanation
Choice A reason : Changing the transparent membrane dressing daily is not necessary unless it's soiled or compromised. The dressing is typically changed every 7 days or per institutional policy to reduce the risk of infection.
Choice B reason: Using a non-coring needle is not applicable for PICC lines as they are designed for use with a luer-lock syringe for medication administration and flushing.
Choice C reason : Maintaining a continuous IV infusion is not required for a PICC line unless clinically indicated. Intermittent use is common for medication administration, and the line should be flushed before and after use to maintain patency.
Choice D reason : Flushing the catheter with a 0.9% sodium chloride solution after each use is the correct action. This helps to maintain catheter patency and prevent occlusion.
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