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 B

Explanation

B. Hypotension suggests inadequate perfusion, which could prompt an increase in dopamine dosage to improve blood pressure and perfusion.

A A heart rate of 60/min is within the normal range for adults and may not necessarily indicate a need to increase dopamine dosage unless accompanied by signs of inadequate perfusion

C. Oxygen saturation of 95% is within the normal range and indicates adequate oxygenation. It does not directly inform the need to increase dopamine dosage

D. A respiratory rate of 14/min is within the normal range. Respiratory rate alone does not typically guide dopamine dosage adjustments unless respiratory distress or acidosis indicates poor tissue perfusion.

A. Arrythmia B. Laryngeal edema C. Hypertension D. Fever

Correct Answer is B

Explanation

B. Laryngeal edema, or swelling of the larynx (voice box), is a hallmark feature of severe anaphylaxis. It can lead to airway obstruction and respiratory distress, which are critical components of an anaphylactic reaction.

A Arrhythmias (abnormal heart rhythms) can occur as a result of various causes, including medications, but they are not specific to anaphylaxis. They may or may not be present during an anaphylactic reaction.

C. Hypertension (high blood pressure) is not a typical feature of anaphylaxis. Instead, hypotension (low blood pressure) is more commonly associated with anaphylactic shock, which is a severe form of anaphylaxis.

D. Fever is not typically associated with anaphylaxis. Anaphylactic reactions typically involve rapid onset of symptoms such as flushing, hives, swelling, respiratory distress, and potentially cardiovascular collapse, but not fever.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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