Question

A nurse is assessing a client who is 2 weeks postoperative following a kidney transplant. Which of the following manifestations should the nurse identify as possible organ rejection?

Answer 1

Correct Answers:

Oliguria.

Rationale :

💎 Oliguria (decreased urine output) can indicate acute rejection of the transplanted kidney, as reduced renal function is a hallmark sign.

💎 Other signs may include hypertension, fever, and graft tenderness, but oliguria is the most direct reflection of impaired renal perfusion or function.

💎 Rejection typically occurs within the first few weeks post-transplant and requires immediate intervention to preserve graft viability.

💎 Monitoring urinary output is a critical postoperative assessment for transplant patients.

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Answer 2

Correct Answers:

Implement a low-sodium diet.
Administer furosemide.
Measure the client's abdominal girth.

Rationale :

⚫Low-sodium diet

💎 Reduces fluid retention and helps manage ascites and edema associated with portal hypertension.

💎 Sodium promotes water retention, worsening complications of cirrhosis.

⚫ Administer furosemide

💎 A loop diuretic used to remove excess fluid in clients with ascites or peripheral edema.

💎 It helps improve respiratory status and abdominal comfort.

⚫ Measure abdominal girth

💎 Regular girth measurements monitor the progression of ascites and response to therapy.

💎 Increasing girth may signal worsening fluid accumulation.

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Answer 3

Correct Answers:

Purulent fluid.

Rationale :

💎 Purulent fluid (thick, yellow, green, or brown) is a strong indicator of infection, typically due to empyema or bacterial invasion of the pleural space.

💎 It often signifies an inflammatory response requiring antibiotic therapy or further drainage.

💎 Thoracentesis should yield clear or straw-colored fluid; purulence is always abnormal.

💎 Prompt reporting and cultures are essential to prevent sepsis.

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Answer 4

Correct Answers:

Alcohol use disorder.

Rationale :

❖ Active alcohol use disorder is a contraindication to kidney transplantation due to risks of nonadherence, hepatic impairment, and poor outcomes post-surgery.

❖ Transplant success depends on strict immunosuppressive regimens, and substance use disorder increases the risk of organ rejection or complications.

❖ Candidates must demonstrate sobriety and compliance before approval.

❖ Cancer in remission, pacemaker use, or age alone are not absolute contraindications.

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Answer 5

Correct Answers:

Movement of the trachea toward the unaffected side.

Rationale :

⚫ Tracheal deviation is a late and life-threatening sign of tension pneumothorax, indicating severe pressure shift in the thoracic cavity.

⚫ This requires immediate intervention, typically needle decompression, to prevent cardiovascular collapse.

⚫ A chest tube in place should relieve air buildup; if not, it suggests malfunction or worsening pneumothorax.

⚫ Early recognition can be lifesaving.

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Answer 6

Correct Answers:

Acidosis.
Ketosis.
Hyperglycemia.

Rationale :

Acidosis

🔵 Diabetic ketoacidosis (DKA) is a state of metabolic acidosis resulting from the accumulation of ketone bodies in the blood.

🔵 These ketones are acidic byproducts of fat metabolism due to insulin deficiency.

🔵 The acidosis contributes to symptoms like Kussmaul respirations, confusion, and abdominal pain.

Ketosis

🔵 Ketosis occurs when the body breaks down fat for energy due to the absence of insulin, producing ketones as a byproduct.

🔵 These ketones accumulate in the blood and urine, contributing to acid-base imbalance.

🔵 Ketone presence is a hallmark feature of DKA and helps confirm the diagnosis.

Hyperglycemia

🔵 Hyperglycemia in DKA is due to an absolute insulin deficiency, leading to elevated blood glucose levels typically >250 mg/dL.

🔵 This triggers osmotic diuresis, dehydration, and electrolyte loss.

🔵 Managing blood glucose is essential in DKA treatment and helps reverse the metabolic abnormalities.

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Answer 7

Correct Answers:

Withhold oral fluids and food.

Rationale :

💎 NPO status prevents stimulation of pancreatic enzymes, which can worsen inflammation in acute pancreatitis.

💎 After pain relief, reducing pancreatic stimulation is the next priority.

💎 Enteral or parenteral nutrition may be considered later once inflammation subsides.

💎 Early refeeding risks further pancreatic injury and systemic complications.

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Answer 8

Correct Answers:

Increased serum amylase.

Rationale :

🔴 Serum amylase levels rise significantly in acute pancreatitis, usually 3x the upper limit of normal.

🔴 It's an early and sensitive marker of pancreatic inflammation.

🔴 Lipase is also elevated, but amylase rises first and peaks sooner.

🔴 Clinical correlation with symptoms confirms diagnosis.

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Answer 9

Correct Answers:

Obtain a prescription for supplemental oxygen.

Rationale :

Hypoxia threatens end-organ damage and is the immediate priority (Airway/Breathing in ABCs). While fluids, insulin, and glucose checks are essential, oxygen corrects tissue hypoxia fastest.

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Answer 10

Correct Answers:

Agitation.

Rationale :

Early hypoxemia causes agitation/restlessness due to cerebral hypoxia. Dysphagia is unrelated; hypotension and cyanosis are late signs.

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QLexNursing

1 :
A nurse is assessing a client who is 2 weeks postoperative following a kidney transplant. Which of the following manifestations should the nurse identify as possible organ rejection?

2 :
A nurse is planning care for a client who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan? (Select all that apply.)

3 :
A nurse is caring for a client who has pleural effusion and has undergone thoracentesis. The nurse should identify which of the following findings as indicative of an infection?

4 :
A nurse is discussing a kidney transplant with a client who has end-stage renal disease (ESRD). Which of the following should the nurse identify as a contraindication for this treatment?

5 :
A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

6 :
A nurse is providing care for a client diagnosed with diabetic ketoacidosis (DK). Which of the following manifestations should the nurse expect? (Select all that apply.)

7 :
A nurse is caring for a client who has acute pancreatitis. After treating the client's pain, which of the following should the nurse address as the priority intervention?

8 :
A nurse admits a client to the emergency department who reports nausea and vomiting that worsens when he lies down. Antacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see?

9 : A nurse is caring for a client who has diabetic ketoacidosis and hypoxia. Which of the following actions should the nurse take first?

10 : A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect?

QLexNursing

1 : A nurse is assessing a client who is 2 weeks postoperative following a kidney transplant. Which of the following manifestations should the nurse identify as possible organ rejection?

2 : A nurse is planning care for a client who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan? (Select all that apply.)

3 : A nurse is caring for a client who has pleural effusion and has undergone thoracentesis. The nurse should identify which of the following findings as indicative of an infection?

4 : A nurse is discussing a kidney transplant with a client who has end-stage renal disease (ESRD). Which of the following should the nurse identify as a contraindication for this treatment?

5 : A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

6 : A nurse is providing care for a client diagnosed with diabetic ketoacidosis (DK). Which of the following manifestations should the nurse expect? (Select all that apply.)

7 : A nurse is caring for a client who has acute pancreatitis. After treating the client's pain, which of the following should the nurse address as the priority intervention?

8 : A nurse admits a client to the emergency department who reports nausea and vomiting that worsens when he lies down. Antacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see?

9 : A nurse is caring for a client who has diabetic ketoacidosis and hypoxia. Which of the following actions should the nurse take first?

10 : A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect?

1 :
A nurse is assessing a client who is 2 weeks postoperative following a kidney transplant. Which of the following manifestations should the nurse identify as possible organ rejection?

2 :
A nurse is planning care for a client who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan? (Select all that apply.)

3 :
A nurse is caring for a client who has pleural effusion and has undergone thoracentesis. The nurse should identify which of the following findings as indicative of an infection?

4 :
A nurse is discussing a kidney transplant with a client who has end-stage renal disease (ESRD). Which of the following should the nurse identify as a contraindication for this treatment?

5 :
A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

6 :
A nurse is providing care for a client diagnosed with diabetic ketoacidosis (DK). Which of the following manifestations should the nurse expect? (Select all that apply.)

7 :
A nurse is caring for a client who has acute pancreatitis. After treating the client's pain, which of the following should the nurse address as the priority intervention?

8 :
A nurse admits a client to the emergency department who reports nausea and vomiting that worsens when he lies down. Antacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see?