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: Lethargy and hypoxia are not typically associated with respiratory alkalosis. Respiratory alkalosis occurs when there is excessive exhalation of carbon dioxide, leading to a decrease in blood CO2 levels and an increase in pH. Lethargy and hypoxia are more often related to respiratory acidosis, where CO2 accumulates due to hypoventilation.

Choice B reason: Light-headedness and muscle spasms are common clinical manifestations of respiratory alkalosis. The decrease in carbon dioxide (CO2) levels leads to cerebral vasoconstriction, resulting in light-headedness or dizziness. Additionally, respiratory alkalosis can cause a shift of calcium in the blood, leading to muscle spasms, tingling, and even tetany.

Choice C reason: Hypotension and respiratory depression are not typical findings in respiratory alkalosis. Hypotension can be a symptom of various conditions but is not directly associated with respiratory alkalosis. Respiratory depression is related to hypoventilation and respiratory acidosis, not hyperventilation.

Choice D reason: Muscle twitching and hyperkalaemia are not manifestations of respiratory alkalosis. Hyperkalaemia is more commonly seen in metabolic acidosis and not in respiratory alkalosis. Muscle twitching can occur in various conditions, but respiratory alkalosis typically causes muscle spasms and tetany due to calcium shifts.

A. A post-operative patient after thyroid surgery preparing for discharge with a new medication B. A patient diagnosed with Cushing's disease after insertion of a nasogastric tube C. A patient scheduled for a chest radiograph who is anxious about their treatment D. A patient with chronic obstructive pulmonary disease who requested a breathing treatment during the previous shift

Correct Answer is D

Explanation

Choice A reason: While a post-operative patient preparing for discharge is important, they are stable enough to be considered for discharge and do not require immediate assessment.

Choice B reason: A patient with Cushing's disease after insertion of a nasogastric tube may need monitoring, but this is not as urgent as a patient with potential respiratory distress.

Choice C reason: A patient scheduled for a chest radiograph who is anxious about their treatment does not require immediate intervention compared to a patient experiencing respiratory issues.

Choice D reason: A patient with chronic obstructive pulmonary disease who requested a breathing treatment during the previous shift may be experiencing respiratory distress and requires immediate assessment and intervention to prevent further complications.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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