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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View Related questions
Correct Answer is A
Explanation
Rationale:
A. Slow, steady bubbling in the suction control chamber indicates that the system is functioning correctly. The nurse should continue to monitor the client's respiratory status and the drainage system.
B. Clamping the chest tube is not indicated unless instructed by the healthcare provider, as it could lead to a dangerous buildup of pressure in the pleural space.
C. Checking the suction control outlet on the wall is not necessary if the suction control chamber is already bubbling steadily.
D. Checking the tubing connections for leaks is unnecessary if the bubbling is slow and steady, as this indicates the system is working properly.
Correct Answer is A
Explanation
Rationale:
A. A rapid weight gain, such as a 5 lb increase in one day, is a strong indicator of fluid overload, particularly in clients with end-stage kidney disease. This excess fluid retention can lead to complications like pulmonary edema and congestive heart failure.
B. An oxygen saturation of 93% is slightly low but not a direct indicator of fluid overload; it may be related to other factors like anemia or underlying lung disease.
C. Normal skin turgor, where the skin returns to its previous position after being pinched, does not indicate fluid overload. In fluid overload, you might see pitting edema, where the skin does not return immediately.
D. Flattened neck veins would suggest a lack of fluid, not an overload. In fluid overload, you would expect to see distended neck veins (jugular venous distension).