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. Soaking the feet is not recommended for clients with diabetes, as it can lead to skin breakdown and increase the risk of infection.
B. While applying lotion to the feet is recommended to keep the skin moisturized, lotion should not be applied between the toes, as this can create a moist environment that promotes fungal infections.
C. Checking the feet daily for sores, bruises, and other injuries is crucial for clients with diabetes to prevent complications like infections and ulcers, which can lead to serious outcomes like amputations if not treated promptly.
D. Wearing sandals exposes the feet to potential injuries and is not recommended for clients with diabetes. It is better to wear well-fitting, closed-toe shoes that provide protection.
Correct Answer is A
Explanation
Rationale:
A. Purulent dialysate outflow is a sign of infection, specifically peritonitis, which is a serious complication of peritoneal dialysis that requires immediate medical attention.
B. Blood-tinged dialysate can occur, especially if the client is new to dialysis or has had recent abdominal surgery, but it should be monitored rather than immediately reported unless it is excessive.
C. A feeling of fullness during the dialysate dwelling phase is common and usually resolves as the body adjusts to the procedure.
D. Discomfort during dialysate inflow can occur, particularly with fast inflow rates or high dialysate volumes, but it is not immediately life-threatening.