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.
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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Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
The nurse should plan to first administer 0.9% sodium chloride followed by Insulin
Rationale
Intravenous fluid resuscitation takes priority in the management of DKA due to the severe dehydration that occurs due to osmotic diuresis.
The next step is to administer intravenous insulin infusion as per the prescribed rate.
Correct Answer is A
Explanation
A A change in level of consciousness (LOC), such as confusion, lethargy, or loss of consciousness, can indicate worsening neurological status. It reflects impaired brain function due to increased pressure on brain tissues.
B. Pupillary changes, such as dilation or asymmetry, can occur due to pressure on the oculomotor nerve (cranial nerve III). Pupillary dilation can be a sign of increased ICP but typically occurs after other neurological changes.
C. Decorticate posturing indicates significant neurological impairment but typically appears after alterations in consciousness.
D. Cheyne-Stokes respirations indicate brainstem involvement and impaired respiratory control but are generally seen later in the progression of neurological deterioration.
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