A nurse is planning care for a client who is 12 hr postoperative following a kidney transplant. Which of the following actions should the nurse include in the plan of care?

Administer opioids PO.

Monitor for hypokalemia as a manifestation of acute rejection.

Assess urine output hourly.

Check the client's blood pressure every 8 hr.

Answer and Explanation

The Correct Answer is C

C. Monitoring urine output is crucial in the early postoperative period after a kidney transplant to assess kidney function and ensure adequate perfusion.

A Managing pain is important, but the administration of opioids should be carefully considered due to their potential to mask symptoms and side effects that could be critical in the postoperative period.

B. While electrolyte imbalances are important to monitor, hypokalemia specifically is not typically associated with acute rejection in the early postoperative period.

D. Blood pressure monitoring every 8 hours may not be sufficient in the immediate postoperative period, especially given the potential for fluid shifts and changes in hemodynamic status.

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Correct Answer is ["C"]

Explanation

A To obtain reliable results, it is generally recommended to collect samples from different areas of the stool across multiple bowel movements rather than from a single sample.

detecting occult blood if it is present in the stool but not evenly distributed throughout. It also helps to reduce the chance of obtaining a false negative result.

C. Urine can interfere with the accuracy of fecal occult blood testing, leading to false positive results. Therefore, any sample that contains visible urine should be discarded to prevent inaccurate test results.

B. While gloves should be worn to maintain standard precautions and prevent direct contact with feces, sterile gloves are not required for this procedure. Standard medical examination gloves are sufficient to ensure hygiene and prevent contamination during sample collection.

D. The guaiac smear should be performed on a small portion of stool obtained from different areas within the bowel movement, not specifically from the outer edge of formed stool. The goal is to sample from different parts to increase the likelihood of detecting any occult blood present.

A. Generalized abdominal pain B. Increased heart rate C. Cloudy effluent D. Fever

Correct Answer is C

Explanation

C. Cloudy effluent is one of the earliest and most specific signs of peritonitis. It warrants immediate evaluation and diagnostic testing to confirm the diagnosis and initiate appropriate treatment.

A Generalized abdominal pain is a common symptom of peritonitis but may not be the earliest indication.

B. Tachycardia (increased heart rate) can occur in response to infection or inflammation, including peritonitis. It is a systemic response rather than a localized symptom.

D. Fever can also be associated with peritonitis but may appear later and is not as specific early indicators

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A nurse is planning care for a client who is 12 hr postoperative following a kidney transplant. Which of the following actions should the nurse include in the plan of care?

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Naxlex Comprehensive Predictor Exams

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