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 B
Explanation
Rationale:
A. A low sodium diet is not appropriate for a client with SIADH and hyponatremia, as it can exacerbate the low sodium levels. Increasing sodium intake might be more appropriate depending on the clinical situation.
B. Restricting fluid intake is a standard treatment for SIADH to prevent further dilution of sodium in the blood, which is critical in managing hyponatremia.
C. Desmopressin acetate is used to treat conditions with insufficient antidiuretic hormone, such as diabetes insipidus, and is not appropriate for SIADH.
D. An IV of 0.45% sodium chloride is hypotonic and could worsen hyponatremia in SIADH. Hypertonic saline would be more appropriate if IV treatment were necessary
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.