A nurse is assisting with the care of a client who has hypertension and chronic kidney disease. The client is scheduled for hemodialysis. Which of the following actions should the nurse plan to take while caring for this client? (Select all that apply.)
Obtain the client’s weight.
Verify the glomerular filtration rate.
Check the graft site for a palpable thrill.
Document vital signs.
Administer a sedative to the client.
Correct Answer : A,C,D
The correct answers are Choices A, C, and D.
Choice A rationale: Obtaining the client's weight is important before and after hemodialysis to assess fluid removal and monitor the patient's fluid balance.
Choice B rationale: Verifying the glomerular filtration rate (GFR) is not necessary immediately before hemodialysis. GFR is typically assessed periodically to monitor kidney function but is not required for each dialysis session.
Choice C rationale: Checking the graft site for a palpable thrill is essential to ensure the arteriovenous (AV) fistula or graft is functioning properly. The thrill indicates that blood is flowing through the access site.
Choice D rationale: Documenting vital signs is crucial before, during, and after hemodialysis to monitor the client's hemodynamic status and detect any complications.
Choice E rationale: Administering a sedative is not a routine part of hemodialysis care. Sedatives may be prescribed for specific situations, but it is not standard practice.
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Related Questions
Correct Answer is A
Explanation
Choice A rationale
Monitoring potassium levels is essential when taking thiazide diuretics because these medications can cause hypokalemia (low potassium levels). Regular blood tests help ensure that potassium levels remain within a safe range.
Choice B rationale
Limiting alcohol consumption to 3 drinks a day is not recommended for individuals with hypertension. Excessive alcohol intake can raise blood pressure and negate the benefits of other lifestyle modifications.
Choice C rationale
Setting a goal body weight within 25% of ideal body weight is not an appropriate recommendation. The goal should be to achieve and maintain a healthy weight, which is typically defined as a BMI within the normal range.
Choice D rationale
Lowering sodium intake to 3,000 mg each day is still above the recommended limit. The American Heart Association recommends reducing sodium intake to less than 2,300 mg per day, with an ideal limit of 1,500 mg per day for most adults.
Correct Answer is B
Explanation
Choice A rationale
Lethargy is not a common side effect of phenazopyridine. This medication is primarily used to relieve urinary tract pain and discomfort.
Choice B rationale
Reddish-orange urine is a common and expected side effect of phenazopyridine. This discoloration is harmless but can stain clothing.
Choice C rationale
Burning during urination is a symptom that phenazopyridine is used to relieve, not a side effect of the medication.
Choice D rationale
Visual disturbances are not commonly associated with phenazopyridine use.
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