The nurse assesses a client shortly after kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?

Correct Answer: D

Rationale: A low urine output of 20mL/hour shortly after kidney transplant surgery is a critical finding that must be reported to the physician immediately. Adequate urine output is essential to ensure proper kidney function and the body's ability to eliminate waste products and regulate electrolyte levels. A urine output of less than 30mL/hour is considered oliguria, which may indicate decreased kidney function or potential complications such as acute kidney injury. Therefore, prompt evaluation and intervention are necessary to prevent further kidney damage or complications in the client.

Correct Answer: D

Rationale: When a client is receiving antibiotics to treat an infection, especially a gram-negative bacterial infection, the antibiotics may disrupt the balance of normal flora in the gastrointestinal tract. This disruption can lead to an overgrowth of pathogenic bacteria, resulting in diarrhea. Clostridium difficile-associated diarrhea is a common complication of antibiotic therapy due to the disruption of normal gut flora. Therefore, the nurse must monitor the client for signs and symptoms of diarrhea and intervene promptly to prevent complications such as dehydration and electrolyte imbalances. Platelet dysfunction, stomatitis, and oliguria/dysuria are not typically associated with the destruction of normal flora due to antibiotic therapy for a gram-negative bacterial infection.

Correct Answer: A

Rationale: The definitive diagnosis of HIV infection is made based on the detection of specific antibodies in the blood. The most commonly used tests for this purpose are ELISA (Enzyme-Linked Immunosorbent Assay) and Western blot. A positive result on both tests confirms the presence of HIV antibodies in the blood, indicating an active HIV infection. High-risk sexual behaviors, extreme weight loss, and opportunistic infections may raise suspicion for HIV infection, but a positive diagnosis is confirmed through specific laboratory tests like ELISA and Western blot.

Correct Answer: B

Rationale: The correct action for the nurse to teach a client with pancytopenia caused by chemotherapy is to avoid traumatic injuries and exposure to any infection. Pancytopenia is a condition characterized by low levels of all blood cell types - red blood cells, white blood cells, and platelets. This leaves the individual vulnerable to infections, easy bruising, and bleeding. By advising the client to avoid traumatic injuries and exposure to infection, the nurse is helping to reduce the risk of further complications that can arise from low blood cell counts. This includes advising the client on taking precautions such as gentle handling to prevent skin injury, using a soft toothbrush for oral care, and avoiding contact with individuals who are sick to minimize the risk of infection.

Correct Answer: B

Rationale: Pallor, or paleness of the skin, is an early sign of anemia. Anemia occurs when there is a decrease in the number of red blood cells or the amount of hemoglobin in the blood, resulting in reduced oxygen supply to the body's tissues. This lack of oxygen can cause the skin to appear pale due to decreased blood flow. Other common symptoms of anemia may include fatigue, weakness, shortness of breath, dizziness, and cold hands and feet. Palpitations, glossitis, and weight loss are not typically early signs of anemia.