Patient Data

Exhibits

Mark whether the assessment finding represents a therapeutic result of the lactulose administered, a nontherapeutic side effect, or an unrelated finding. Each row must have one option selected.

A. Advise the client that the healthcare provider (HCP) needs to be made aware of the current diet: Green leafy vegetables are high in vitamin K, which can interfere with the effectiveness of warfarin by promoting clotting. The healthcare provider must be informed to adjust the medication dose if necessary or provide specific dietary guidance.

B. Suggest that the client replace the leafy vegetables with a protein source such as nuts or beans: Advising the client to eliminate green vegetables is not appropriate because sudden changes in vitamin K intake can destabilize warfarin therapy. Consistency in vitamin K consumption is key rather than abrupt dietary changes.

C. Confirm that the client's diet choices will help the medication be more effective in preventing blood clots: Regular consumption of vitamin K-rich foods without dose adjustment can decrease warfarin's anticoagulant effect, increasing the risk of clot formation. The current diet does not inherently support the intended action of the medication.

D. Commend the client for a healthy lifestyle and encourage the client to continue current diet habits: Although a diet rich in vegetables is generally healthy, with warfarin therapy, any vitamin K intake must be consistent and properly managed. Simply encouraging the client without notifying the provider could lead to therapeutic failure.

A. Temperature of 100.8° F (38.2° C): A mildly elevated temperature in a post-transplant client may suggest infection or early rejection, both of which warrant monitoring. However, this is not a direct reason to withhold cyclosporine, which is essential for preventing organ rejection.

B. Elevated blood urea nitrogen (BUN): Elevated BUN could indicate impaired renal function, which should be monitored during cyclosporine therapy. However, this alone is not an urgent reason to withhold the medication without further evaluation of kidney function trends and symptoms.

C. Renal output of 120 mL/hour: This is a healthy urine output and suggests good renal perfusion and function. It does not present any contraindication to continuing cyclosporine and supports that the transplanted kidney is functioning well.

D. Blood pressure 180/98 mm Hg: Hypertension is a known side effect of cyclosporine and can become severe. A blood pressure this high, especially when accompanied by headache and blurred vision, suggests possible cyclosporine-induced hypertensive crisis or toxicity, and warrants immediate withholding of the medication and notification of the HCP.