The charge nurse is assigning semiprivate rooms for new admissions. Which patient could safely be assigned as a roommate for a patient who has acute rejection of an organ transplant?
A patient with an anaphylactic reaction
A patient who has viral pneumonia
A patient with graft-versus-host disease
A patient with second degree burns
The Correct Answer is B
A. A patient with anaphylactic reaction may have unpredictable clinical course and require immediate interventions, which could affect the stability of the roommate.
B. A patient with viral pneumonia poses a lower risk of infection transmission to an immunocompromised patient with acute organ rejection compared to other options.
C. Graft-versus-host disease indicates an immunocompromised state and poses infection risks, similar to acute rejection patients.
D. Second degree burns also pose infection risks and would not be suitable for a roommate of a patient with acute organ rejection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Applying calamine lotion can provide relief from itching but does not address potential complications such as swelling or allergic reactions.
B. Applying ice packs can help reduce swelling and pain, but it is not the priority action in this scenario.
C. Attempting to remove the patient's rings is crucial to prevent complications such as restricted blood flow due to swelling, which can be exacerbated by bee stings. However, this should be done after administering diphenhydramine.
D. The nurse should first administer diphenhydramine (Benadryl) 50 mg PO to counteract the effects of the bee venom and reduce the risk of anaphylaxis.
Correct Answer is []
Explanation
Potential Condition:
Hypovolemia: The client shows signs of hypovolemia such as a low blood pressure (94/56 mm Hg), a high heart rate (110/min), and a relatively high urine output (1500 mL in the last hour), which may indicate an over-diuresis or inadequate fluid replacement postoperatively.
Actions to Take:
Obtain prescription for IV bolus: Administering an IV fluid bolus can help restore intravascular volume, thereby increasing blood pressure and improving perfusion to vital organs.
Lower head of bed: This action helps to increase venous return to the heart, which can help improve cardiac output and blood pressure in a hypovolemic patient.
Parameters to Monitor:
Urinary output: This is a key indicator of kidney function and fluid status. Monitoring urine output will help determine if the client is adequately responding to fluid resuscitation and maintaining appropriate kidney function.
Blood pressure: Continuous blood pressure monitoring is essential to evaluate the effectiveness of interventions aimed at correcting hypovolemia and ensuring the client's hemodynamic stability.
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