Question

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?

Answer 1

Correct Answers:

Oliguria.

Rationale :

🧪Oliguria indicates a possible rejection of a transplanted kidney due to decreased kidney function and reduced urine output.

🔥Rejection typically presents with signs of kidney dysfunction, such as decreased urine output, fever, hypertension, and graft tenderness.

🚨A temperature of 36.1°C is within normal limits and does not suggest an infection or rejection process.

⚖️Weight loss and insomnia are nonspecific symptoms and are not reliable indicators of acute transplant rejection.

📌Core Message

Oliguria is a primary indicator of kidney transplant rejection because it reflects impaired renal function and possible graft failure.

Answer 2

Correct Answers:

Implement a low-sodium diet.
Administer furosemide.
Measure the client's abdominal girth.

Rationale :

🍲A low-sodium diet is essential in clients with cirrhosis to reduce fluid retention and the development of ascites.

💊Furosemide, a loop diuretic, is commonly used to manage fluid overload in cirrhosis by promoting diuresis and reducing peripheral edema and ascites.

📏Measuring abdominal girth helps monitor ascites, which is a common complication of liver cirrhosis, and tracks treatment effectiveness.

🛑Warfarin is contraindicated in liver disease due to the liver’s impaired ability to produce clotting factors, increasing the risk of bleeding.

🏋️‍♂️Encouraging weight lifting is not appropriate due to the risk of increased intra-abdominal pressure and potential complications like variceal bleeding or hernias.

📌Core Message

Management of cirrhosis includes fluid control, monitoring for ascites, and avoiding anticoagulants and strenuous activities that may worsen complications.

Answer 3

Correct Answers:

Purulent fluid.

Rationale :

🦠Purulent fluid is indicative of infection because it contains pus, which is made up of white blood cells, dead cells, and bacteria.

🧫Infected pleural effusion (empyema) is characterized by thick, cloudy, or purulent fluid from the pleural space.

🩸Bloody fluid may suggest trauma or malignancy but is not diagnostic of infection.

🥛Milky or chylous fluid can indicate chylothorax, often due to lymphatic obstruction, not infection.

🧴Viscous fluid may result from certain malignancies or proteinaceous effusions but does not confirm infection without the presence of pus.

📌Core Message

Purulent fluid following thoracentesis indicates infection (empyema) and should be reported and managed promptly.

Answer 4

Correct Answers:

Alcohol use disorder.

Rationale :

🚫Active alcohol use disorder is a contraindication for kidney transplantation because it significantly increases the risk of nonadherence to immunosuppressive therapy.

🧬Post-transplant success requires strict medication compliance, and individuals with substance abuse are often unable to meet this requirement.

🎗️A history of breast cancer in remission and the presence of a pacemaker do not inherently disqualify a client from receiving a transplant.

📉Age alone (such as 65 years) is not a barrier as long as the client’s overall functional status is acceptable for surgery and recovery.

📌Core Message

Active alcohol use disorder disqualifies clients from kidney transplantation due to the high risk of noncompliance and poor postoperative management.

Answer 5

Correct Answers:

Movement of the trachea toward the unaffected side.

Rationale :

⚠️Tracheal deviation away from the affected side is a hallmark of a tension pneumothorax, which requires emergency intervention.

💨This shift occurs due to air trapped in the pleural space, causing increased pressure that pushes the mediastinum away.

🧼Bubbling with exhalation and non-visible chest tube eyelets are expected and not cause for immediate concern.

🫧Crepitus may indicate subcutaneous air, but it is less urgent than signs of mediastinal shift like tracheal deviation.

📌Core Message

Tracheal deviation to the unaffected side suggests tension pneumothorax, which is a critical complication of chest tube insertion.

Answer 6

Correct Answers:

Acidosis
Ketosis
Hyperglycemia

Rationale :

💉Hyperglycemia is a hallmark feature of DKA due to an absolute insulin deficiency, which prevents glucose uptake into cells and leads to excessive blood sugar levels.

🔥The body compensates by breaking down fat for energy, resulting in ketosis, where ketone bodies accumulate in the blood.

📉The ketone accumulation leads to metabolic acidosis, which is why acidosis is a defining characteristic of DKA.

🚫Low blood sugar, alkalosis, and fluid overload are not associated with DKA and would suggest different pathologies or complications.

📌Core Message

DKA is defined by hyperglycemia, ketosis, and acidosis, all caused by insulin deficiency and the body's switch to fat metabolism for energy.

Answer 7

Correct Answers:

Withhold oral fluids and food.

Rationale :

🚫NPO status is necessary in acute pancreatitis to avoid stimulating the pancreas and worsening inflammation.

💥Pancreatic stimulation from oral intake leads to release of digestive enzymes, which exacerbate tissue damage.

🛌Although positioning and comfort are important, they are not as critical as pancreatic rest in early management.

🧼Oral hygiene is supportive care but does not address the core pathophysiology of pancreatitis.

📌Core Message

In acute pancreatitis, keeping the client NPO is the priority intervention after pain relief to ensure pancreatic rest.

Answer 8

Correct Answers:

Increased serum amylase.

Rationale :

🧫Amylase is a digestive enzyme released by the pancreas, and its elevated levels are diagnostic of acute pancreatitis.

📊Amylase levels rise early in the disease process due to leakage from inflamed pancreatic tissue.

🧪Although lipase is also elevated, amylase is more commonly measured for initial diagnosis.

⚠️Low calcium or WBC changes may occur, but they are not primary diagnostic markers like amylase.

📌Core Message

Increased serum amylase is an early and primary indicator of acute pancreatitis, reflecting pancreatic enzyme release.

Answer 9

Correct Answers:

Obtain a prescription for supplemental oxygen.

Rationale :

🌬️Oxygenation is the immediate priority for a client with hypoxia, regardless of concurrent conditions like DKA.

📉Tissue hypoxia worsens metabolic acidosis, so addressing low oxygen levels prevents further deterioration.

💉Although insulin and fluids are essential, they do not correct the oxygen deficit, which is life-threatening.

🩺The ABCs of emergency care guide the nurse to prioritize airway and breathing first.

📌Core Message

Oxygen therapy takes precedence in clients with DKA and hypoxia to ensure tissue oxygenation and survival.

Answer 10

Correct Answers:

Agitation.

Rationale :

😠Agitation is an early sign of hypoxemia due to reduced oxygen delivery to the brain, leading to altered behavior.

🫁In asthma attacks, bronchoconstriction limits airflow, causing oxygen deprivation and subsequent neurological changes.

⚠️Signs like dysphagia, nausea, and hypotension may occur later or reflect unrelated issues.

🔍Monitoring for restlessness and anxiety helps in early detection and intervention of low oxygen states.

📌Core Message

Agitation is a key early sign of hypoxemia during asthma attacks, reflecting neurological response to low oxygen levels.

ATI Med Surg 2 Respiratory exam

No.

1 :
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?

2 :
A nurse is planning care for a client who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan? (Select all that apply.)

3 :
A nurse is caring for a client who has pleural effusion and has undergone thoracentesis. The nurse should identify which of the following findings as indicative of an infection?

4 :
A nurse is discussing kidney transplant with a client who has end-stage renal disease (ESRD). Which of the following should the nurse identify as a contraindication for this treatment?

5 :
A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

6 :
A nurse is providing care for a client diagnosed with diabetic ketoacidosis (DKA). Which of the following are expected findings? Select all that apply.

7 :
A nurse is caring for a client who has acute pancreatitis. After treating the client's pain, which of the following should the nurse address as the priority intervention?

8 :
A nurse admits a client to the emergency department who reports nausea and vomiting that worsens when he lies down. Antacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see?

9 :
A nurse is caring for a client who has diabetic ketoacidosis and hypoxia. Which of the following actions should the nurse take first?

10 :
A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect?

ATI Med Surg 2 Respiratory exam

No.

1 : 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?

2 : A nurse is planning care for a client who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan? (Select all that apply.)

3 : A nurse is caring for a client who has pleural effusion and has undergone thoracentesis. The nurse should identify which of the following findings as indicative of an infection?

4 : A nurse is discussing kidney transplant with a client who has end-stage renal disease (ESRD). Which of the following should the nurse identify as a contraindication for this treatment?

5 : A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

6 : A nurse is providing care for a client diagnosed with diabetic ketoacidosis (DKA). Which of the following are expected findings? Select all that apply.

7 : A nurse is caring for a client who has acute pancreatitis. After treating the client's pain, which of the following should the nurse address as the priority intervention?

8 : A nurse admits a client to the emergency department who reports nausea and vomiting that worsens when he lies down. Antacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see?

9 : A nurse is caring for a client who has diabetic ketoacidosis and hypoxia. Which of the following actions should the nurse take first?

10 : A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect?

1 :
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?

2 :
A nurse is planning care for a client who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan? (Select all that apply.)

3 :
A nurse is caring for a client who has pleural effusion and has undergone thoracentesis. The nurse should identify which of the following findings as indicative of an infection?

4 :
A nurse is discussing kidney transplant with a client who has end-stage renal disease (ESRD). Which of the following should the nurse identify as a contraindication for this treatment?

5 :
A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

6 :
A nurse is providing care for a client diagnosed with diabetic ketoacidosis (DKA). Which of the following are expected findings? Select all that apply.

7 :
A nurse is caring for a client who has acute pancreatitis. After treating the client's pain, which of the following should the nurse address as the priority intervention?

8 :
A nurse admits a client to the emergency department who reports nausea and vomiting that worsens when he lies down. Antacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see?

9 :
A nurse is caring for a client who has diabetic ketoacidosis and hypoxia. Which of the following actions should the nurse take first?

10 :
A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect?