The nurse obtains initial vital signs on a patient 2 weeks posttransplant who presents for follow-up monitoring to the outpatient transplant clinic. Which assessment finding by the nurse requires immediate action?
a. Blood pressure of 100/60 mm Hg
b. Serum creatinine of 1.5 mg/dL
c. Hemoglobin of 9.2 gm/dL
d. Tenderness over graft site
D
Tenderness over the graft site may be indicative of acute rejection in a renal transplant recipient 2 weeks posttransplant. Blood pressure, serum creatinine, and hemoglobin values are all within acceptable ranges and do not require immediate action.
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