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 D
Explanation
Rationale:
A. While administering oxygen can help with overall oxygenation, it does not specifically address the issue of thick, tenacious secretions.
B. A low-salt diet might be indicated for other health concerns but does not directly impact bronchial secretions.
C. Semi-Fowler's position can help with lung expansion and ease of breathing but does not directly assist with loosening secretions.
D. Drinking 2 to 3 liters of water daily helps to thin bronchial secretions, making it easier for the client to expectorate (cough up) the mucus, which is particularly important in managing COPD.
Correct Answer is B
Explanation
Rationale:
A. Drowsiness is not typically associated with thyrotoxicosis; rather, clients are more likely to experience restlessness or insomnia.
B. Heat intolerance is a common symptom of thyrotoxicosis, reflecting the increased metabolic rate associated with excessive thyroid hormone levels.
C. Bradycardia is associated with hypothyroidism, not thyrotoxicosis. In thyrotoxicosis, tachycardia or palpitations are more likely.
D. Dry skin is a symptom of hypothyroidism, whereas in thyrotoxicosis, the skin may become warm, moist, and flushed.