Answer to Question 1
3
Rationale: The client's operative arm should be positioned so that it is elevated on one or two pillows and does not exceed shoulder elevation. This promotes optimal drainage from the limb, without impairing the circulation to the arm. If the arm is positioned flat (level with the right-sided atrium) or dependent (dependent to the right-sided atrium), this could increase the edema in the arm, which is contraindicated because of lymphatic disruption caused by surgery.
Answer to Question 2
3
Rationale: To avoid toxicity from high medication levels and to avoid organ rejection from low medication levels, blood levels of cyclosporine should be measured periodically. In the organ transplant client, an immunosuppressant will need to be taken for life. Oral administration is the route of choice; IV administration is reserved for clients who cannot take the medication orally. The most serious adverse effects are nephrotoxicity and infection.
The patient and his family meet with the nurse to discuss progress on the patient care plan.
The nurse uses a noninvasive bladder ultrasound to measure the client’s bladder volume.
nursing team
nursing process
Nursing Concept
Nursing intervention classification