# A nurse is evaluating a 35-year-old client during a routine outpatient visit 4 years after kidney transplantation. The client reports a 3-day history of low-grade fever and decreased urine output. Vital signs: temperature 38.4 C (101.1 F), blood pressure 158/96 mm Hg, heart rate 102. Laboratory: serum creatinine 2.5 mg/dL (baseline 1.2), BUN 38 mg/dL, urine output 480 mL in the past 24 hours. Tenderness is noted over the transplanted kidney site. Which actions should the nurse implement? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=368098&lang=en  
> language: en  
> subject: System-Specific Assessments  
> category: ROR

## Question

A nurse is evaluating a 35-year-old client during a routine outpatient visit 4 years after kidney transplantation. The client reports a 3-day history of low-grade fever and decreased urine output. Vital signs: temperature 38.4 C (101.1 F), blood pressure 158/96 mm Hg, heart rate 102. Laboratory: serum creatinine 2.5 mg/dL (baseline 1.2), BUN 38 mg/dL, urine output 480 mL in the past 24 hours. Tenderness is noted over the transplanted kidney site. Which actions should the nurse implement? Select all that apply.

1

Notify the transplant nephrologist immediately about the doubled creatinine, fever, and tenderness over the graft site

2

Review medication adherence including immunosuppressant timing, missed doses, and recent infections

3

Hold all immunosuppressant medications, including tacrolimus and prednisone, until the next clinic visit

4

Assess the transplanted kidney site for tenderness, induration, asymmetry, and changes in graft size

5

Reassure the client that mild creatinine elevation is expected and reschedule a follow-up visit in 2 weeks

6

Obtain a CBC with differential, complete metabolic panel, and tacrolimus trough level

## Explanation

Acute kidney transplant rejection presents with rising creatinine (often doubled), fever, hypertension, oliguria, and graft tenderness. Immediate notification of the transplant team is critical because biopsy and intravenous methylprednisolone pulse therapy may be needed within hours to preserve the graft. Standard workup includes CBC/CMP and tacrolimus trough (a subtherapeutic level suggests nonadherence) plus direct graft assessment. Reassuring the client (option 5) delays diagnosis and risks graft loss. Holding immunosuppressants (option 3) precipitates rejection rather than treating it; immunosuppressants are never withheld without transplant team direction.

## In-depth explanation

Acute Rejection Picture
Doubled creatinine (1.2 to 2.5) plus fever plus oliguria plus graft tenderness equals textbook acute rejection. Window for graft salvage is hours, not days.

Immediate Actions
1. Notify transplant nephrologist now — biopsy and pulse methylprednisolone may be needed.
2. Send CBC, CMP, tacrolimus trough — a low level points to missed doses.
3. Direct graft assessment (tenderness, induration, asymmetry).
4. Adherence review — late rejection beyond one year is most often driven by nonadherence.

Wrong Answers
Option 3: Reassurance delays diagnosis and risks graft loss.
Option 5: Never hold immunosuppressants without transplant team direction — that is the opposite of what is needed.

NCSBN Theme
ROR (Reduction of Risk Potential) — recognize complications and take immediate action.

## Clinical scenario

Scenario
35-year-old male, post kidney transplant 4 years ago, here for routine clinic visit.

Symptoms
- 3 days of low-grade fever (38.4 C / 101.1 F)
- Decreased urine output (480 mL in 24 hours)
- Tenderness over transplanted kidney site

Vital Signs
- BP 158/96 mm Hg / HR 102

Labs
- Creatinine 2.5 mg/dL (baseline 1.2)
- BUN 38 mg/dL
- Tacrolimus trough pending

Key Cue
Doubled creatinine plus fever plus oliguria plus graft tenderness equals acute rejection until proven otherwise.

## Key concepts

- **Acute graft rejection** — An immune reaction against the transplanted organ. Acute kidney rejection typically appears 1 week to several months post-op, but late rejection beyond 1 year is also possible. Hallmarks include rising creatinine, fever, hypertension, oliguria, and graft tenderness. Treatment: pulse IV methylprednisolone with or without rituximab or antithymocyte globulin.
- **Tacrolimus (Prograf)** — A calcineurin inhibitor and the main immunosuppressant after transplant. Therapeutic trough varies but is commonly 5 to 10 ng/mL in the late post-op period. Subtherapeutic levels suggest nonadherence or drug interactions; supratherapeutic levels cause nephrotoxicity. Always draw the trough just before the next dose.
- **Acute kidney injury vs rejection** — In a transplant client, AKI must be distinguished from rejection. Clues for rejection: rising creatinine over days to weeks, fever, graft tenderness, and hypertension. Workup: tacrolimus level, ultrasound with resistive index, and biopsy (gold standard).

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