A nurse is assisting with the care of a client who has hypertension and chronic kidney disease. The client is scheduled for hemodialysis. Which of the following actions should the nurse plan to take while caring for this client? (Select all that apply.)
Obtain the client’s weight.
Verify the glomerular filtration rate.
Check the graft site for a palpable thrill.
Document vital signs.
Administer a sedative to the client.
Correct Answer : A,C,D
The correct answers are Choices A, C, and D.
Choice A rationale: Obtaining the client's weight is important before and after hemodialysis to assess fluid removal and monitor the patient's fluid balance.
Choice B rationale: Verifying the glomerular filtration rate (GFR) is not necessary immediately before hemodialysis. GFR is typically assessed periodically to monitor kidney function but is not required for each dialysis session.
Choice C rationale: Checking the graft site for a palpable thrill is essential to ensure the arteriovenous (AV) fistula or graft is functioning properly. The thrill indicates that blood is flowing through the access site.
Choice D rationale: Documenting vital signs is crucial before, during, and after hemodialysis to monitor the client's hemodynamic status and detect any complications.
Choice E rationale: Administering a sedative is not a routine part of hemodialysis care. Sedatives may be prescribed for specific situations, but it is not standard practice.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A 2-hour blood glucose level of 132 mg/dL is below the threshold for diabetes diagnosis, which is 200 mg/dL or higher.
Choice B rationale
An HbA1c level of 5.2% is within the normal range. Diabetes is diagnosed with an HbA1c of 6.5% or higher.
Choice C rationale
A casual blood glucose level of 178 mg/dL is elevated but not diagnostic of diabetes. Diabetes is diagnosed with a casual blood glucose level of 200 mg/dL or higher.
Choice D rationale
A fasting blood glucose level of 155 mg/dL is above the threshold for diabetes diagnosis, which is 126 mg/dL or higher. This indicates that the client is at risk for diabetes mellitus.
Correct Answer is A
Explanation
Choice A rationale
Rifampin can cause discoloration of body fluids, including tears, which can stain contact lenses. Therefore, it is recommended to wear glasses instead of contacts while taking this medication.
Choice B rationale
A yellow tint to the skin is not an expected reaction to rifampin. This could indicate jaundice, a sign of liver dysfunction, which requires immediate medical attention.
Choice C rationale
Lifelong treatment with rifampin is not necessary. The typical duration of treatment for active tuberculosis is 6 to 9 months.
Choice D rationale
Rifampin does not cause amenorrhea when taken with oral contraceptives. However, it can reduce the effectiveness of oral contraceptives, so additional contraceptive methods should be used.
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