The nurse is caring for a patient who is experiencing disequilibrium syndrome during hemodialysis. Which of the following interventions will the nurse implement for this patient? (Select All That Apply)

Administer a rapid infusion of fluids.

Increase the dialysis flow rate.

Decrease the rate of dialysis.

Apply ice packs to the patient's head.

Monitor neurological status closely.

Answer and Explanation

Correct Answer : C

Choice A reason: Administering a rapid infusion of fluids is not appropriate for disequilibrium syndrome. This syndrome results from rapid changes in fluid and electrolyte balance during dialysis, and rapid fluid infusion could worsen the condition.

Choice B reason: Increasing the dialysis flow rate is not appropriate. Decreasing the rate of dialysis can help reduce the symptoms of disequilibrium syndrome by allowing the body to adjust more gradually.

Choice C reason: Decreasing the rate of dialysis helps to minimize the rapid shifts in fluid and electrolytes, which can exacerbate disequilibrium syndrome.

Choice D reason: Applying ice packs to the patient's head is not a standard intervention for disequilibrium syndrome. The focus should be on managing the rate of dialysis and monitoring the patient's neurological status.

Choice E reason: Monitoring neurological status closely is important because disequilibrium syndrome can cause symptoms such as headache, nausea, confusion, and seizures. Close monitoring allows for prompt intervention if symptoms worsen.

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Correct Answer is B

Explanation

Choice A reason: Notifying the blood bank of the suspected transfusion reaction is important, but maintaining the IV access with normal saline infusion takes priority to ensure that the patient remains stable and to prevent any further complications.

Choice B reason: Maintaining IV access with normal saline infusion is the first priority. This action helps to keep the vein open, provide fluids, and flush out any remaining blood product from the IV line, reducing the risk of further reaction.

Choice C reason: Facilitating the transfer of the patient to the critical care unit may be necessary if the patient's condition worsens, but it is not the immediate first step.

Choice D reason: Rechecking identification labels and numbers is important to confirm the correct blood product was given, but it comes after ensuring the patient’s stability by maintaining IV access with saline.

A. "I will take this medication as needed during flares of joint pain." B. "I will avoid drinking alcohol while taking this medication." C. "I will call my provider if I develop a sore throat or fever." D. "I will use contraception while taking this medication."

Correct Answer is A

Explanation

Choice A reason: Methotrexate is a disease-modifying antirheumatic drug (DMARD) that must be taken regularly as prescribed, not just during flares of joint pain. It helps to prevent disease progression and joint damage. This statement indicates a misunderstanding of the medication regimen and requires further teaching.

Choice B reason: Avoiding drinking alcohol while taking methotrexate is important because alcohol can increase the risk of liver damage, a potential side effect of methotrexate. This statement indicates proper understanding.

Choice C reason: Calling the provider if a sore throat or fever develops is important because methotrexate can suppress the immune system, increasing the risk of infections. This statement indicates proper understanding.

Choice D reason: Using contraception while taking methotrexate is crucial because methotrexate can cause birth defects. This statement indicates proper understanding.

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The nurse is caring for a patient who is experiencing disequilibrium syndrome during hemodialysis. Which of the following interventions will the nurse implement for this patient? (Select All That Apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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