The nurse is administering intravenous (IV) fluids to a patient undergoing hemodialysis. Which action is most important for the nurse to take to ensure patient safety during the procedure?

Check the patient's blood pressure before and after the IV administration.

Ensure the dialysis access site is used for IV administration when possible.

Verify the correct fluid type and rate as per the physician's order.

Monitor for signs of infiltration or extravasation at the IV site.

Answer and Explanation

The Correct Answer is C

Choice A reason: Checking the patient's blood pressure before and after IV administration is important, but it is not the most critical action to ensure safety during the procedure.

Choice B reason: Ensuring the dialysis access site is used for IV administration when possible is not standard practice. The dialysis access site is typically reserved for dialysis treatments to prevent complications.

Choice C reason: Verifying the correct fluid type and rate as per the physician's order is the most important action. Ensuring the right fluid type and rate prevents potential complications such as fluid overload, electrolyte imbalances, and adverse reactions.

Choice D reason: Monitoring for signs of infiltration or extravasation at the IV site is important, but verifying the correct fluid type and rate takes precedence to prevent any errors in the initial setup.

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Correct Answer is B

Explanation

Choice A reason: Scattered petechiae on bilateral lower extremities are a common finding in patients with thrombocytopenia, indicating low platelet count and increased risk of bleeding. While this finding is concerning, it is not as immediate a threat as significant bleeding or bruising.

Choice B reason: Ecchymosis around the intravenous site suggests significant bleeding and bruising, which can be more urgent and requires immediate reporting. A platelet count of 10,000/mm³ is critically low, increasing the risk of spontaneous bleeding and haemorrhage. Immediate intervention is necessary to prevent further complications.

A. pH 7.46, PaCO2 30, HCO3 24 B. pH 7.48, PaCO2 45, HCO3 29 C. pH 7.26, PaCO2 59, HCO3 30 D. pH 7.31, PaCO2 34, HCO3 18

Correct Answer is A

Explanation

Choice A reason: The lab results pH 7.46, PaCO2 30, HCO3 24 indicate respiratory alkalosis, which can occur due to hyperventilation. In pulmonary edema, the patient may hyperventilate to compensate for reduced oxygenation, leading to a decrease in carbon dioxide (PaCO2) and an increase in pH (alkaline).

Choice B reason: The lab results pH 7.48, PaCO2 45, HCO3 29 indicate metabolic alkalosis with partial compensation. This is not consistent with hyperventilation in pulmonary edema, where respiratory alkalosis is more likely.

Choice C reason: The lab results pH 7.26, PaCO2 59, HCO3 30 indicate respiratory acidosis with partial compensation. This finding suggests hypoventilation, which is not expected in a patient hyperventilating due to pulmonary edema.

Choice D reason: The lab results pH 7.31, PaCO2 34, HCO3 18 indicate metabolic acidosis with partial compensation. This is not typical in a patient with hyperventilation and pulmonary edema.

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The nurse is administering intravenous (IV) fluids to a patient undergoing hemodialysis. Which action is most important for the nurse to take to ensure patient safety during the procedure?

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