# A nurse is caring for a 45-year-old client who received a kidney transplant 6 months ago and is maintained on tacrolimus, mycophenolate, and prednisone. The client reports fatigue, low-grade fever (100.2°F), and decreased urine output over the past 3 days. Laboratory results show elevated serum creatinine and BUN levels. What is the priority nursing intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=540870 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a 45-year-old client who received a kidney transplant 6 months ago and is maintained on tacrolimus, mycophenolate, and prednisone. The client reports fatigue, low-grade fever (100.2°F), and decreased urine output over the past 3 days. Laboratory results show elevated serum creatinine and BUN levels. What is the priority nursing intervention? ## 보기 1. Increase fluid intake to improve kidney function 2. Administer acetaminophen for fever reduction 3. Encourage bed rest to conserve energy 4. Notify the transplant team immediately **✔ 정답** **정답: 4** ## 해설 Post-transplant patients with fatigue, fever, decreased urine output, and elevated creatinine/BUN may have acute rejection or infection. Immediate notification of the transplant team is essential for prompt evaluation and intervention. ## 심화 해설 Understanding the Clinical Presentation The client is presenting with a classic triad concerning for acute rejection or a serious opportunistic infection in a renal transplant recipient: fatigue, low-grade fever, and decreased urine output with rising serum creatinine and BUN. In the context of a maintenance immunosuppressive regimen of tacrolimus, mycophenolate, and prednisone, these signs and symptoms are red flags for graft dysfunction. The priority is not to manage individual symptoms but to address the underlying threat to the transplanted organ. Analyzing the Priority Intervention The correct answer is to notify the transplant team immediately. The rationale is rooted in the pathophysiology of transplant rejection and the narrow therapeutic window for intervention. - Graft Rejection: The elevated serum creatinine and BUN indicate a decline in glomerular filtration rate, a hallmark of acute rejection. This is a medical emergency where irreversible nephron damage can occur rapidly. - Immunosuppression and Infection: The combination of fatigue and low-grade fever in an immunocompromised host must be assumed to be a serious infection until proven otherwise. A common and devastating pathogen in this population is Cytomegalovirus (CMV). As highlighted in the provided evidence by Lodha et al., CMV viremia in a renal transplant recipient can present insidiously and lead to severe end-organ damage, including tissue-invasive disease and graft dysfunction [1]. The source material demonstrates that CMV can manifest with non-specific symptoms like fatigue and fever while directly impacting renal function, mimicking or coexisting with rejection. - Clinical Judgment: The nurse’s immediate role is to recognize this as a critical change in condition and activate the rapid response system for transplant patients—the transplant team. The team will coordinate urgent diagnostics (e.g., renal ultrasound, CMV PCR, donor-specific antibodies) and interventions (e.g., high-dose corticosteroids, antiviral therapy). Delaying this notification to implement comfort measures like administering acetaminophen or encouraging bed rest is unsafe and could lead to graft loss. Why Other Options Are Incorrect - Option 1: Increase fluid intake. This is contraindicated without knowing the cause of the decreased urine output. If the client is in acute rejection or has acute tubular necrosis, aggressive fluid resuscitation could lead to hypervolemia, hypertension, and pulmonary edema, especially given the potential for concurrent heart failure as seen in the case from the source material [1]. - Option 2: Administer acetaminophen. This treats a symptom (fever) but masks a critical diagnostic clue. In an immunocompromised patient, fever is a key sign of infection or rejection, and its suppression delays definitive diagnosis and treatment. - Option 3: Encourage bed rest. While conserving energy is a supportive measure, it does not address the life- and organ-threatening process of acute graft dysfunction. This is a low-priority intervention in an acute crisis. The case from the provided evidence reinforces this priority. The patient in the source material, a renal transplant recipient, presented with a complex clinical picture where an infection (CMV) led to a severe systemic response and organ dysfunction, requiring immediate and coordinated specialist intervention [1]. This mirrors the critical nature of a transplant patient presenting with fever and rising creatinine, where only the transplant team can rapidly differentiate between rejection and infection and initiate the correct, often opposing, treatments.References (research sources) - [1]Cytomegalovirus (CMV) Viremia Presenting as a Heart Failure Exacerbation.Research articleLodha C, Basile EJ, Singireddy S. (2026) · DOI: 10.7759/cureus.108181 ## 임상 시나리오 Renal Transplant: Acute DeteriorationRecognizing and Responding to Graft Dysfunction The classic triad of fever, decreased urine output, and rising serum creatinine in a transplant recipient is a red flag for acute rejection or serious opportunistic infection (e.g., CMV). This is a time-sensitive emergency. The priority nursing action is to notify the transplant team immediately. Do not delay for independent interventions like fluid boluses or antipyretics, which can mask symptoms or cause harm (e.g., fluid overload in oliguria). CautionA low-grade fever (100.2°F) in an immunocompromised client is significant. Never assume it is a minor viral illness. Prompt blood work (including tacrolimus trough and CMV PCR) and hospitalization are typically required. ## 핵심 개념 - **Acute Rejection** — An immune response by the recipient's body against the transplanted organ, often presenting with fever, graft tenderness, and elevated creatinine; a medical emergency requiring prompt intervention. - **Tacrolimus** — A calcineurin inhibitor immunosuppressant used to prevent organ rejection; requires therapeutic drug monitoring due to its narrow therapeutic index and nephrotoxic potential. - **Cytomegalovirus (CMV)** — A common opportunistic viral infection in transplant recipients on immunosuppression, which can cause fever, fatigue, and end-organ damage including graft dysfunction. - **Serum Creatinine** — A waste product from muscle metabolism filtered by the kidneys; rising levels indicate a decline in glomerular filtration rate and potential kidney injury. ## 같은 주제 문제 - [A nurse is caring for a client who received a kidney transplant 3 months ago. 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