,Verified NUR 265 Exam 4 Test Bank & Guaranteed
Success Exam Prep Guide | Advanced Medical
Surgical Nursing | Galen College of Nursing
1. The nurse is caring for a client who had a liver transplant 48 hours ago. It is a priority for the
nurse to notify the primary healthcare provider (PHCP) if the client has:
A) Scant amounts of serosanguinous drainage from the incision
B) A urine output that has decreased from 65 to 45 mL/hr since surgery
C) An increasing bilirubin level
D) An increase in blood pressure from 115/68 to 122/74
Correct Answer: C) An increasing bilirubin level
Rationale: An increasing bilirubin level in a post-liver transplant client is a sign of possible
hepatic rejection or biliary obstruction. Serosanguinous drainage, a urine output of 45 mL/hr,
and a slight increase in blood pressure are expected or not immediately concerning. The
provider must be notified promptly of any indication of declining graft function.
2. The nurse is caring for a client who had a lung transplant 10 days ago. It is a priority for the
nurse to notify the PHCP if the client has:
A) Only used the incentive spirometer once since last evening
B) Developed sputum that is yellow-tinged
C) A pain rating of 7/10 when taking a deep breath
D) Refused high-frequency chest wall oscillation for the past 24 hours
,Correct Answer: B) Developed sputum that is yellow-tinged
Rationale: Yellow-tinged sputum in a post-lung transplant client indicates possible infection.
Immunosuppressed transplant recipients are at high risk for infection, which can quickly
become life-threatening. The provider must be notified immediately. Poor incentive spirometer
use, pain, and refusal of treatment are important but secondary to signs of infection.
3. The nurse is caring for a client who had a kidney transplant 2 weeks ago. Which findings
should the nurse correlate with possible organ rejection?
A) Blood pressure of 116/66 and serum potassium level of 4.0
B) Serum creatinine level of 2.5, serum potassium level of 5.8, and BUN level of 30
C) Urinalysis positive for protein and blood pressure of 116/66
D) Serum creatinine of 1.0 and BUN of 12
Correct Answer: B) Serum creatinine level of 2.5, serum potassium level of 5.8, and BUN level of
30
Rationale: Acute rejection of a kidney transplant is characterized by elevated serum creatinine,
elevated BUN, and hyperkalemia. These findings indicate declining renal function and require
immediate provider notification. Normal blood pressure, normal creatinine (1.0), and normal
BUN (12) are not concerning. Proteinuria may also be present.
4. A client who received a kidney transplant is prescribed cyclosporine. The nurse should
monitor for which adverse effect?
A) Nephrotoxicity
, B) Hepatotoxicity
C) Cardiotoxicity
D) Ototoxicity
Correct Answer: A) Nephrotoxicity
Rationale: Cyclosporine is a calcineurin inhibitor immunosuppressant that can cause
nephrotoxicity. Renal function should be monitored closely. It can also cause hypertension and
hyperlipidemia.
5. A client who received a kidney transplant is being monitored for signs of rejection. Which
finding is most concerning for acute rejection?
A) Fever and tenderness over the graft site
B) Urine output of 50 mL/hr
C) Serum creatinine of 1.2 mg/dL
D) Blood pressure of 130/80 mmHg
Correct Answer: A) Fever and tenderness over the graft site
Rationale: Fever and tenderness over the graft site are signs of acute rejection. Urine output of
50 mL/hr, creatinine of 1.2 mg/dL, and blood pressure of 130/80 mmHg are within acceptable
ranges.
Success Exam Prep Guide | Advanced Medical
Surgical Nursing | Galen College of Nursing
1. The nurse is caring for a client who had a liver transplant 48 hours ago. It is a priority for the
nurse to notify the primary healthcare provider (PHCP) if the client has:
A) Scant amounts of serosanguinous drainage from the incision
B) A urine output that has decreased from 65 to 45 mL/hr since surgery
C) An increasing bilirubin level
D) An increase in blood pressure from 115/68 to 122/74
Correct Answer: C) An increasing bilirubin level
Rationale: An increasing bilirubin level in a post-liver transplant client is a sign of possible
hepatic rejection or biliary obstruction. Serosanguinous drainage, a urine output of 45 mL/hr,
and a slight increase in blood pressure are expected or not immediately concerning. The
provider must be notified promptly of any indication of declining graft function.
2. The nurse is caring for a client who had a lung transplant 10 days ago. It is a priority for the
nurse to notify the PHCP if the client has:
A) Only used the incentive spirometer once since last evening
B) Developed sputum that is yellow-tinged
C) A pain rating of 7/10 when taking a deep breath
D) Refused high-frequency chest wall oscillation for the past 24 hours
,Correct Answer: B) Developed sputum that is yellow-tinged
Rationale: Yellow-tinged sputum in a post-lung transplant client indicates possible infection.
Immunosuppressed transplant recipients are at high risk for infection, which can quickly
become life-threatening. The provider must be notified immediately. Poor incentive spirometer
use, pain, and refusal of treatment are important but secondary to signs of infection.
3. The nurse is caring for a client who had a kidney transplant 2 weeks ago. Which findings
should the nurse correlate with possible organ rejection?
A) Blood pressure of 116/66 and serum potassium level of 4.0
B) Serum creatinine level of 2.5, serum potassium level of 5.8, and BUN level of 30
C) Urinalysis positive for protein and blood pressure of 116/66
D) Serum creatinine of 1.0 and BUN of 12
Correct Answer: B) Serum creatinine level of 2.5, serum potassium level of 5.8, and BUN level of
30
Rationale: Acute rejection of a kidney transplant is characterized by elevated serum creatinine,
elevated BUN, and hyperkalemia. These findings indicate declining renal function and require
immediate provider notification. Normal blood pressure, normal creatinine (1.0), and normal
BUN (12) are not concerning. Proteinuria may also be present.
4. A client who received a kidney transplant is prescribed cyclosporine. The nurse should
monitor for which adverse effect?
A) Nephrotoxicity
, B) Hepatotoxicity
C) Cardiotoxicity
D) Ototoxicity
Correct Answer: A) Nephrotoxicity
Rationale: Cyclosporine is a calcineurin inhibitor immunosuppressant that can cause
nephrotoxicity. Renal function should be monitored closely. It can also cause hypertension and
hyperlipidemia.
5. A client who received a kidney transplant is being monitored for signs of rejection. Which
finding is most concerning for acute rejection?
A) Fever and tenderness over the graft site
B) Urine output of 50 mL/hr
C) Serum creatinine of 1.2 mg/dL
D) Blood pressure of 130/80 mmHg
Correct Answer: A) Fever and tenderness over the graft site
Rationale: Fever and tenderness over the graft site are signs of acute rejection. Urine output of
50 mL/hr, creatinine of 1.2 mg/dL, and blood pressure of 130/80 mmHg are within acceptable
ranges.
