520 Organ Transplant
A nurse assesses a client shortly after living donor kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately? a. Serum potassium level of 4.9 mEq/L b. Urine output of 20 ml/hour c. Temperature of 99.2° F (37.3° C) d. Serum sodium level of 135 mEq/L
b. Urine output of 20 ml/hour Explanation: Because kidney transplantation carries the risk of transplant rejection, infection, and other serious complications, the nurse should monitor the client's urinary function closely. A decrease from the normal urine output of 30 ml/hour is significant and warrants immediate physician notification. A serum potassium level of 4.9 mEq/L, a serum sodium level of 135 mEq/L, and a temperature of 99.2° F are normal assessment findings.
The nurse is delegating care of client with neutropenia who is in isolation to an unlicensed assistive personnel (UAP). What information should the nurse give the UAP about the care of this client? a. completing all of the client's care for the shift at one time b. listening and responding to the client's feelings of concern c. instructing the client to dispose of the tissue after blowing the nose d. completing the client's care in a calm, unhurried manner
b. instructing the client to dispose of the tissue after blowing the nose Explanation: The most common source of infection and microbial colonization in neutropenic clients is their own nonpathogenic normal flora. Attention to personal hygiene, such as oral, pulmonary, urinary, and rectal care, is essential. It is important to acknowledge the client's concerns and fears and to provide organized, calm, compassionate care, but it is more important to teach the client how to prevent an infection that could be life-threatening.
A complete blood count is commonly performed before a client goes into surgery. What does this test seek to identify? a. Low levels of urine constituents normally excreted in the urine b. Electrolyte imbalance that could affect the blood's ability to coagulate properly c. Potential hepatic dysfunction indicated by decreased blood urea nitrogen (BUN) and creatinine levels d. Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
d. Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels Explanation: Low preoperative HCT and Hb levels indicate the client may require a blood transfusion before surgery. If the HCT and Hb levels decrease during surgery because of blood loss, the potential need for a transfusion increases. Possible renal failure is indicated by elevated BUN or creatinine levels. Urine constituents aren't found in the blood. Coagulation is determined by the presence of appropriate clotting factors, not electrolytes.
A female client is receiving chemotherapy and is experiencing pancytopenia. Which laboratory result most warrants that the nurse immediately contact the health care provider (HCP)? a. hemoglobin of 12 g/100mL b. absolute neutrophil count of 1,500/mm3 c. WBC count of 4,000/mm3 d. platelet count of 12,000/mm3
d. platelet count of 12,000/mm3 Explanation: Pancytopenia means a decrease in all blood components. Because a platelet count of less than 15,000/mm3 can result in spontaneous bleeding, the nurse notifies the HCP of this laboratory result. Neutrophils are a type of WBC. An absolute neutrophil count between 1,000 and 1,800/mm3 suggests mild neutropenia and represents a low risk of infection. Although references vary, normal range for WBC counts are 5,000 to 11,000/mm3, and a female's normal hemoglobin (Hgb) value is roughly 12 to 16 g/100 ml. Therefore, the WBC count and Hgb levels are a bit low, but not critical.
The nurse is caring for a client being discharged following kidney transplantation. The client is ordered mofetil to prevent organ rejection. Which nursing instruction is essential regarding medication use? a. Contact the health care provider at first signs of an infection. b. Sprinkle the contents of the capsule on food. c. Administer the medication with an antacid to prevent stomach upset. d. Administer medication following breakfast daily.
a. Contact the health care provider at first signs of an infection. Explanation: Mofetil is an organ rejection medication that diminishes the body's ability to identify and eliminate pathogens (immunosuppressant). Identifying symptoms of infection at an early state is helpful in treating the infection. This medication is administered on an empty stomach. Typically, capsules would not be opened dispensing medication at one time. Antacids may decrease the absorption of the medication.
A client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system, the nurse states that humoral immunity is provided by which type of white blood cell? a. Lymphocyte b. Monocyte c. Neutrophil d. Basophil
a. Lymphocyte Explanation: The lymphocyte provides humoral immunity — recognition of a foreign antigen and formation of memory cells against the antigen. Humoral immunity is mediated by B and T lymphocytes and can be acquired actively or passively. The neutrophil is crucial to phagocytosis. The basophil plays an important role in the release of inflammatory mediators. The monocyte functions in phagocytosis and monokine production.
Twenty-four hours after undergoing kidney transplantation, a client develops a hyperacute rejection. To correct this problem, the nurse should prepare the client for a. removal of the transplanted kidney. b. intra-abdominal instillation of methylprednisolone sodium succinate. c. bone marrow transplant. d. high-dose I.V. cyclosporine therapy.
a. removal of the transplanted kidney. Explanation: Hyperacute rejection isn't treatable; the only way to stop this reaction is to remove the transplanted organ or tissue. Although cyclosporine is used to treat acute transplant rejection, it doesn't halt hyperacute rejection. Bone marrow transplant isn't effective against hyperacute rejection of a kidney transplant. Methylprednisolone sodium succinate may be given I.V. to treat acute organ rejection, but it's ineffective against hyperacute rejection.
A client with severe arthritis has been receiving maintenance therapy of prednisone 10 mg/day for the past 6 weeks. The nurse should instruct the client to immediately report which symptom? a. joint swelling b. constipation c. joint pain d. respiratory infection
d. respiratory infection Explanation: Clients receiving chronic steroid therapy can become immunosuppressed and are prone to infections. Signs of infection can also be masked with prednisone. Signs and symptoms of infection should be reported immediately. Joint pain, constipation, and joint swelling are not related to the adverse effects of steroid therapy.
The nurse is providing discharge teaching for a client with neutropenia. When discussing types of fruits and vegetables that the client likes, which are encouraged? Select all that apply. a. cooked corn b. bananas c. a green salad d. broccoli florets e. canned peaches f. carrot sticks
e. canned peaches a. cooked corn Explanation: A client with a compromised immune system and low white blood cell count (neutropenia) is at high risk for infection. Foods can introduce infections; thus, the client is encourages to eat cooked or prepared fruits and vegetables. Canned peaches have been processed and thoroughly cooked corn is appropriate. Raw fruits and vegetables are not allowed because they may contain microbial contamination.
The nurse is caring for a client who is scheduled to undergo a bone marrow aspiration to assess the progression of a hematologic disorder. Which interventions would the nurse include as part of the preprocedural teaching plan? Select all that apply. a. Instruct the client to save all voided urine for 24 hours after the procedure. b. Explain the procedure to the client. c. Encourage the client to ask questions before obtaining the signed informed consent. d. Maintain a pressure dressing over the aspiration site. e. Administer an anxiety-relieving medication prior to the procedure. f. Explain that the client will receive an analgesic prior to the procedure.
b. Explain the procedure to the client. c. Encourage the client to ask questions before obtaining the signed informed consent. f. Explain that the client will receive an analgesic prior to the procedure. Explanation: The preprocedure teaching extends from when the procedure is first discussed through when the procedure begins. The client would understand the procedure and the reason why it is necessary before signing an informed consent form. The client would be advised of the local analgesia or anti-anxiety medication to be administered before the procedure begins. Maintaining pressure over the insertion site is a nursing intervention performed after the procedure; it is not a part of the preoperative teaching. Instructing the client to save voided urine would be part of the postprocedural discharge plan.
