A nurse is caring for a client undergoing hemodialysis. What is the nurse's priority action during dialysis?
Monitoring the client's blood pressure and heart rate.
Assisting the client with dietary s during mealtime.
Providing emotional support and encouragement.
Administering prescribed intravenous medications.
The Correct Answer is A
A. Correct. Monitoring the client's blood pressure and heart rate is a priority during dialysis to assess the client's hemodynamic status and detect any potential complications, such as hypotension or arrhythmias.
B. Incorrect. While assisting with dietary s is important, it is not the priority during the dialysis procedure.
C. Incorrect. Providing emotional support is essential, but the nurse's priority during dialysis is to monitor the client's vital signs and ensure their safety during the procedure.
D. Incorrect. Administering prescribed intravenous medications may be necessary during dialysis, but it is not the priority action stated in this question.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) This statement is incorrect. Monitoring hemoglobin levels is essential for clients with ESRD and during hemodialysis, but it is not directly related to the administration of heparin.
B) This statement is accurate. While a drop in platelet count is not uncommon during heparin administration, the nurse should closely monitor the client's platelet count to detect any significant changes or potential complications related to heparin-induced thrombocytopenia.
C) This statement is incorrect. Monitoring blood glucose levels is important, especially for clients with diabetes or those at risk of hypoglycemia during dialysis, but it is not specifically related to heparin administration.
D) This statement is incorrect. Monitoring blood urea nitrogen (BUN) levels is crucial for clients with ESRD, but it is not directly related to the administration of heparin during hemodialysis.
QUESTIONS
Correct Answer is C
Explanation
A. Incorrect. Collecting a sample of the effluent for culture and sensitivity testing may be necessary, but notifying the healthcare provider about the finding should be done first.
B. Incorrect. Stopping the exchange immediately may be necessary in some cases, but the nurse should first communicate the finding to the healthcare provider for further assessment and guidance.
C. Correct. Cloudy dialysate effluent may indicate peritonitis, an infection of the peritoneal cavity, which requires immediate attention and treatment by the healthcare provider.
D. Incorrect. Encouraging the client to perform another exchange without further assessment can potentially exacerbate any underlying issue causing the cloudy effluent.
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