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 A
Explanation
Choice A reason: Including more cantaloupe in the diet is a good practice for a client on furosemide therapy. Cantaloupe is high in potassium, and furosemide can cause hypokalemia (low potassium levels) as it is a potent diuretic that increases urine production and the excretion of various electrolytes, including potassium. Therefore, consuming foods rich in potassium can help counteract this potential adverse effect.
Choice B reason: Checking the pulse before taking the medication is a general safety measure but does not directly relate to a specific adverse effect of furosemide. While it's important to monitor heart rate, especially in clients with heart failure, this statement does not reflect an understanding of the adverse effects related to furosemide.
Choice C reason: Trying to limit foods that contain salt is an appropriate action for a client with heart failure but is not directly related to an adverse effect of furosemide. Reducing salt intake can help manage heart failure by preventing fluid retention; however, it does not address the specific adverse effects of furosemide therapy.
Choice D reason: Checking blood pressure to ensure it doesn't get too high is important for clients with heart failure but does not indicate an understanding of the adverse effects of furosemide. Furosemide is used to reduce excess fluid in the body, which can lower blood pressure, not increase it. This statement does not reflect an understanding of furosemide's potential to cause electrolyte imbalances.
Correct Answer is D
Explanation
Choice A reason: Removing the weights before changing the client's bed linens is not recommended. The weights are an integral part of the traction system and removing them could disrupt the traction, potentially causing harm or discomfort to the client. The weights must be maintained to ensure the effectiveness of the skeletal traction.
Choice B reason: Instructing the client to use their elbows to reposition themselves could be helpful, but it is not the primary action the nurse should take. While maintaining some degree of mobility is important, the nurse must ensure that the traction setup is not disturbed during any movement.
Choice C reason: Checking pressure points every 12 hours is important to prevent skin breakdown and ulcers, especially in immobilized patients. However, this is a routine action and not specific to the care of a client with skeletal traction. The nurse should check pressure points more frequently, considering the increased risk of pressure sores in immobilized patients.
Choice D reason: Providing the client with a trapeze bar is the correct action. A trapeze bar allows the client to independently reposition themselves while maintaining the integrity of the traction. It helps the client to move and shift weight, which can aid in preventing complications such as pressure ulcers and muscle atrophy. It also gives the client a sense of control and independence in their care.
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