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 ["A","B","C","E"]
Explanation
Rationale:
A. A decreased level of consciousness is a common symptom of ARF due to hypoxemia, which reduces oxygen delivery to the brain, leading to confusion, agitation, or lethargy.
B. Hypercarbia, or elevated levels of carbon dioxide (CO2) in the blood, occurs due to impaired gas exchange in ARF, which leads to respiratory acidosis.
C. Severe dyspnea, or difficulty breathing, is a hallmark symptom of ARF as the lungs fail to maintain adequate oxygenation or ventilation.
D. Nausea is not a typical manifestation of ARF; while it may occur due to other factors, it is not directly associated with respiratory failure.
E. Tachycardia, or an increased heart rate, is often seen in ARF as the body attempts to compensate for hypoxemia by increasing cardiac output to deliver more oxygen to tissues.
Correct Answer is A
Explanation
Rationale:
A. Auscultating for a bruit at the site of an AV graft is the most appropriate method to assess its patency. A bruit is a sound made by turbulent blood flow, indicating that the graft is functioning.
B. Measuring blood pressure in both arms does not specifically assess the patency of the graft and could potentially harm the graft if measured in the affected arm.
C. Auscultating the antecubital fossa using a Doppler is not a standard practice for assessing AV graft patency; instead, a stethoscope is used directly over the graft site.
D. Checking the brachial and radial pulses does not assess the graft directly. Although pulse presence is important, it does not provide information about the graft’s patency.