The nurse is caring for a child recovering from a kidney transplant. Which nursing diagnosis should the nurse identify as the priority to guide the care for this patient?
A) Pain related to tissue rejection
B) Constipation related to effects of administered drugs
C) Risk for infection related to immunocompromised state
D) Deficient fluid volume related to fluid intake restrictions postoperatively
C
Feedback:
After renal transplantation, children are cared for in an environment that is as sterile as possible as they are placed on immunosuppressive therapy to reduce the possibility of kidney rejection. Immunosuppressive therapy increases the patient's risk of developing an infection. The priority nursing diagnosis at this time is the risk for infection. Tissue rejection would not be immediate. The patient's pain would be from the surgical site. There is no information to support that the patient's medication will cause constipation. It is unlikely that the patient will be on a fluid restriction after surgery since there is a need to evaluate the functioning of the transplanted kidney.
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