The nurse is planning care for the client who will be returning to the unit after a cardiac transplant. A priority of care for this client would be:
1. Monitoring for bleeding.
2. Frequent oral care.
3. Keeping the skin clean and dry.
4. Limiting visitation.
Answer: 1
1. One of the immediate needs of a postoperative transplant client is monitoring for bleeding, which includes monitoring blood pressure and cardiac output.
2. Oral care is important to prevent infection, but monitoring for bleeding is the priority.
3. Bleeding is one of the top priorities. When the client is reasonably stable, the nurse addresses skin care.
4. The nurse does not limit visitation unless the visitor shows signs of infection.
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