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?
Temperature 36.1°C (97.0° F)
Weight loss
Insomnia
Oliguria
The Correct Answer is D
Rationale:
A. A low temperature is not indicative of organ rejection; fever would be more concerning.
B. Weight loss is not a typical sign of acute organ rejection; weight gain due to fluid retention might be observed.
C. Insomnia is not specifically associated with organ rejection.
D. Oliguria (decreased urine output) is a significant sign of possible kidney transplant rejection, as it may indicate impaired kidney function.
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Correct Answer is C
Explanation
Rationale:
A. Soaking the feet is not recommended for clients with diabetes, as it can lead to skin breakdown and increase the risk of infection.
B. While applying lotion to the feet is recommended to keep the skin moisturized, lotion should not be applied between the toes, as this can create a moist environment that promotes fungal infections.
C. Checking the feet daily for sores, bruises, and other injuries is crucial for clients with diabetes to prevent complications like infections and ulcers, which can lead to serious outcomes like amputations if not treated promptly.
D. Wearing sandals exposes the feet to potential injuries and is not recommended for clients with diabetes. It is better to wear well-fitting, closed-toe shoes that provide protection.
Correct Answer is D
Explanation
Rationale:
A. Adjusting the rate of the bladder irrigation might be necessary, but it is not the first action to take when there is no drainage.
B. Ambulating the client can help promote bladder function, but it is not the immediate priority when assessing catheter function.
C. Notifying the provider is important if the issue cannot be resolved, but the nurse should first attempt to resolve common, simple issues like a kinked tube.
D. Checking the tubing for kinks is the most immediate and logical first action to take. Kinks in the tubing can obstruct urine flow, and correcting this can often resolve the issue without further intervention.