# A nurse is caring for a client who received a heart transplant 1 year ago and is on immunosuppressive therapy. The client presents with fever, fatigue, and decreased urine output. Which nursing intervention should be the priority?

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## 문제

A nurse is caring for a client who received a heart transplant 1 year ago and is on immunosuppressive therapy. The client presents with fever, fatigue, and decreased urine output. Which nursing intervention should be the priority?

## 보기

1. Administer acetaminophen for fever reduction and monitor response.
2. Encourage increased fluid intake to improve urine output
3. Implement strict isolation precautions and notify the physician immediately **✔ 정답**
4. Monitor vital signs every 4 hours and document findings

**정답: 3**

## 해설

Fever, fatigue, and decreased urine output in an immunocompromised transplant patient indicate a potential life-threatening infection requiring immediate isolation and provider notification. Other options address symptoms but do not prioritize infection control.

## 심화 해설

Clinical Context & Why This Is the Priority

This client is one year post-heart transplant and maintained on immunosuppressive therapy. The triad of fever, fatigue, and decreased urine output in an immunocompromised host is a classic presentation of a systemic infection, which can rapidly progress to sepsis and acute kidney injury. The immediate threat is not the fever or the oliguria in isolation, but the underlying infectious process that can quickly overwhelm a patient with a blunted immune response. Solid organ transplant recipients are at heightened risk for both common and atypical infections, including those caused by multidrug-resistant organisms and opportunistic pathogens, which can present with nonspecific symptoms and deteriorate swiftly [2]. Therefore, the priority is to protect the patient from further nosocomial infection and to urgently escalate care for diagnostic workup and targeted therapy.

Analysis of the Correct Answer (Option 3)

Implement strict isolation precautions and notify the physician immediately is the correct priority action. This intervention directly addresses the two most critical nursing responsibilities in this scenario: infection control and patient safety. The client's immunosuppressed state means they are both highly vulnerable to acquiring new infections and potentially harboring a transmissible pathogen. Initiating strict isolation protects the client and others while the team investigates the source. Simultaneously, immediate physician notification is essential because the presentation suggests a serious systemic infection, which in transplant recipients can be caused by a broad spectrum of bacteria, including multidrug-resistant organisms, and may require urgent diagnostic procedures and empiric antimicrobial therapy [2]. Delaying this communication could lead to irreversible septic shock.

Why the Other Options Are Not the Priority

- Option 1 (Administer acetaminophen): While fever management is a comfort measure and can reduce metabolic demand, it is a secondary intervention. Administering an antipyretic without addressing the underlying cause masks a critical clinical sign and delays definitive treatment. In an immunocompromised patient, a fever is a key indicator of a potentially life-threatening infection that requires immediate investigation, not just symptomatic relief.

- Option 2 (Encourage increased fluid intake): Decreased urine output in this context is more likely a sign of developing acute kidney injury secondary to sepsis or medication toxicity than simple dehydration. Encouraging oral fluids is an inappropriate and potentially dangerous intervention for a patient who may be progressing to acute renal failure and septic shock. This patient requires intravenous access, fluid resuscitation guided by hemodynamic monitoring, and a strict intake and output record, all of which are part of a physician-directed medical plan.

- Option 4 (Monitor vital signs every 4 hours): Monitoring is a fundamental nursing function, but the frequency of every 4 hours is insufficient for a patient with signs of a systemic inflammatory response. A septic patient requires continuous monitoring or, at minimum, vital signs every hour. More importantly, assessment alone does not constitute an intervention that will alter the trajectory of a rapidly progressing infection. The nurse must act on the findings by initiating infection control and reporting immediately.

Pathophysiology and Clinical Reasoning Connection

Immunosuppressive therapy impairs T-cell function, which is critical for fighting intracellular pathogens and coordinating the overall immune response. This creates a vulnerability to infections that are uncommon in the general population and allows typical infections to present in an "out of pattern" manner—with atypical timing, severity, or symptoms . For example, a tick-borne illness like ehrlichiosis, which normally peaks in summer, can occur in winter in a transplant recipient and manifest with fever, malaise, and multiorgan involvement, including renal impairment . The nurse's clinical judgment must link the combination of immunosuppression, fever, and end-organ hypoperfusion (suggested by oliguria) to the highest risk: systemic infection progressing to severe sepsis. The immediate nursing action is therefore to isolate and report, which sets the stage for all subsequent diagnostic and therapeutic interventions.References (research sources)

- [2]Global challenges of bacterial infections in organ transplantation: assessment of risk factors and predominant bacterial pathogen profiles threatening liver, kidney, heart, and lung transplant recipients.Research articleMoradi F, Bahrami M, Nasrollahian S, Shirazi PS, Ghoreyshi NS, Ghobadi M. (2025) · DOI: 10.1186/s12879-025-11579-x

## 임상 시나리오

Infection in the Immunocompromised Transplant PatientEarly Recognition and Immediate Nursing Priorities
In any solid organ transplant recipient on immunosuppressive therapy, a triad of fever, fatigue, and decreased urine output must be treated as a systemic infection until proven otherwise. The blunted immune response can mask classic signs, leading to rapid deterioration into sepsis and acute kidney injury.

The first and most critical nursing action is to implement strict isolation precautions and notify the physician immediately. This simultaneously protects the patient from nosocomial pathogens and contains any potentially transmissible organism they may be harboring. Do not delay isolation for a confirmed diagnosis.

CautionDo not prioritize comfort measures like antipyretics or encourage fluid intake without a provider order. In a patient with new-onset oliguria, fluid administration can precipitate pulmonary edema if renal function is compromised. Routine vital sign monitoring is important but secondary to immediate infection control and escalation of care.

## 핵심 개념

- **Immunosuppressive Therapy** — Medications used to dampen the immune system to prevent organ rejection, which simultaneously increase the risk of severe and atypical infections.
- **Systemic Infection** — An infection that has spread throughout the body, often presenting with nonspecific symptoms like fever and fatigue, and can rapidly progress to sepsis in immunocompromised hosts.
- **Strict Isolation Precautions** — A set of infection control measures designed to prevent the transmission of highly contagious or epidemiologically important pathogens, protecting both the patient and others.
- **Oliguria** — Decreased urine output, which in this context is a critical sign of potential sepsis-induced acute kidney injury rather than simple dehydration.

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