Nokea
After teaching a client who is recovering from pancreas transplantation, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional education?
- A. If I develop an infection, I should stop taking my corticosteroid.
- B. If I have pain over the transplant site, I will call the surgeon immediately.
- C. I should avoid people who are ill or who have an infection.
- D. I should take my cyclosporine exactly the way I was taught.
Correct Answer: A
Rationale: Stopping corticosteroids during an infection without consulting the transplant physician can endanger the graft. The other statements are correct, as pain may indicate rejection, avoiding infections is crucial, and adherence to cyclosporine is essential.
You may also like to solve these questions
A nurse cares for a client with diabetes mellitus who asks, 'Why do I need to administer more than one injection of insulin each day?' How should the nurse respond?
- A. You need to start with multiple injections until you become more proficient at self-injection.
- B. A single dose of insulin each day would not match your blood insulin levels and your food intake patterns.
- C. A regimen of a single dose of insulin injected each day would require that you eat fewer carbohydrates.
- D. A single dose of insulin would be too large to be absorbed, putting you at risk for insulin shock.
Correct Answer: B
Rationale: Multiple insulin injections are needed to match insulin levels with food intake and activity patterns, preventing wide blood glucose fluctuations. Proficiency in injection, carbohydrate restriction, or absorption issues are not the primary reasons for multiple doses.
A nurse assesses a client with diabetes mellitus and notes the client only responds to a sternal rub by moaning, has a capillary blood glucose of 33 mg/dL, and has an intravenous line that is infiltrated with 0.45% normal saline. Which action should the nurse take first?
- A. Administer 1 mg of intramuscular glucagon.
- B. Encourage the client to drink orange juice.
- C. Insert a new intravenous access line.
- D. Administer 25 mL dextrose 50% (D50) IV push.
Correct Answer: A
Rationale: The client's severe hypoglycemia (blood glucose 33 mg/dL) and unresponsiveness require immediate treatment. Intramuscular glucagon is the priority since the IV line is infiltrated, and oral intake is not feasible. Inserting a new IV or administering D50 IV can follow once access is restored.
A nurse is teaching a client with diabetes mellitus who asks, 'Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL?' How should the nurse respond?
- A. Glucose is the only fuel used by the body to produce the energy that it needs.
- B. Your brain needs a constant supply of glucose because it cannot store it.
- C. Without a minimum level of glucose, your body does not make red blood cells.
- D. Glucose in the blood prevents the formation of lactic acid and prevents acidosis.
Correct Answer: B
Rationale: Because the brain cannot synthesize or store significant amounts of glucose, a continuous supply from the body's circulation is needed to meet the fuel demands of the central nervous system. The nurse should educate the client to prevent hypoglycemia. The body can use other sources of fuel, including fat and protein, and glucose is not directly involved in the production of red blood cells. Glucose in the blood does not directly prevent lactic acid formation.
A nurse reviews laboratory results for a client with diabetes mellitus who is prescribed an intensified insulin regimen: Fasting blood glucose: 75 mg/dL, Postprandial blood glucose: 200 mg/dL, Hemoglobin A1c level: 5.5%. How should the nurse interpret these laboratory findings?
- A. Increased risk for developing ketoacidosis.
- B. Good control of blood glucose.
- C. Increased risk for developing hyperglycemia.
- D. Signs of insulin resistance.
Correct Answer: B
Rationale: These values (fasting glucose 75 mg/dL, A1c 5.5%) indicate good glycemic control in an intensified insulin regimen. Postprandial glucose of 200 mg/dL is slightly high but not indicative of ketoacidosis, hyperglycemia risk, or insulin resistance.
A nurse cares for a client who is diagnosed with acute rejection 2 months after receiving a simultaneous pancreas-kidney transplant. The client states, 'I was doing so well with my new organs, and the thought of having to go back to living on hemodialysis and taking insulin is so depressing.' How should the nurse respond?
- A. Following-Drug regimen more closely would have prevented this.
- B. One acute rejection episode does not mean that you will lose the new organs.
- C. Dialysis is a viable treatment option for you and may save your life.
- D. Since you are on the national registry, you can receive a second transplantation.
Correct Answer: B
Rationale: An acute rejection episode does not necessarily lead to organ loss, as immunosuppressive therapy can often manage it. Blaming the client, emphasizing dialysis, or discussing retransplantation is not supportive or accurate in this context.