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. Assisting the client to the bathroom might be helpful, but it is not the first action the nurse should take since the client hasn't voided for an extended period.
B. Increasing fluids may be beneficial but does not address the immediate concern of whether there is a problem with urinary retention.
C. Performing a bladder scan is the first action to determine if there is urine retention in the bladder. This information is crucial before deciding on further interventions, such as catheterization.
D. Inserting a straight catheter may be necessary if significant urinary retention is confirmed, but it should not be the first action without knowing the bladder's status.
Correct Answer is ["A","C","D","E"]
Explanation
Rationale:
A. The nurse should inform the client that if the stockings are too tight, they may impair blood flow rather than prevent it, which could increase the risk of complications such as pressure sores or circulatory issues.
B. While the stockings should be removed periodically, removing them only once daily for 30 minutes may not be sufficient for skin inspection and care. Best practice usually involves removing them more frequently, such as every 8 hours, to check for skin integrity.
C. Proper skin hygiene and regular assessment should be performed each time the stockings are removed to ensure there is no irritation, breakdown, or circulatory impairment.
D. Antiembolism stockings are designed to be worn both in and out of bed to maintain consistent pressure on the legs and reduce the risk of deep vein thrombosis (DVT).
E. Proper measuring of the leg is crucial to ensure that the stockings fit correctly, providing the necessary compression without being too tight or too loose.