A nurse is caring for a client post hemodialysis. The nurse assesses bleeding at the AV fistula site, the nurse should prioritize which of the following actions?

Obtain a complete blood count (CBC)

Start IV fluids

Apply direct pressure

Administer pain medication

Answer and Explanation

The Correct Answer is C

A. Obtain a complete blood count (CBC): This is not the immediate action in an active bleeding scenario.

B. Start IV fluids: This may be needed later if significant blood loss occurs, but not the first response.

C. Apply direct pressure: Bleeding from a fistula requires immediate direct pressure to prevent blood loss and preserve vascular access.

D. Administer pain medication: Pain management is important but not the priority in acute bleeding.

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Correct Answer is C

Explanation

A. Omeprazole: Not directly nephrotoxic, but long-term use has been associated with interstitial nephritis, although rarely.

B. Ondansetron: Generally safe in renal disease and not known to cause nephrotoxicity.

C. Vancomycin: Known nephrotoxic agent, especially with high trough levels or when used with other nephrotoxins; requires dose adjustment in CKD.

D. Diphenhydramine: Not nephrotoxic; primarily affects the CNS and anticholinergic systems.

A. Evaluating the patient's level of pain after medication administration B. Ensuring a bag valve mask (BVM) is at the bedside. C. Verification of allergies to medications. D. Documenting the level of pain before medication administration

Correct Answer is B

Explanation

A. Evaluating the patient's level of pain after medication administration: This is important but comes after the medication is given.

B. Ensuring a bag valve mask (BVM) is at the bedside: Opioids and sedatives depress respiratory drive. Emergency resuscitation equipment (like a BVM) must be ready in case of respiratory compromise.

C. Verification of allergies to medications: Important, but verifying allergies should already be done before administering any meds; not the priority here.

D. Documenting the level of pain before medication administration: Also important, but secondary to safety preparation.

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A nurse is caring for a client post hemodialysis. The nurse assesses bleeding at the AV fistula site, the nurse should prioritize which of the following actions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Explanation

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