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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Monitoring intake and output is important but not the first priority. The immediate concern is to address the client’s pain.
Choice B rationale
Administering pain medication is the first priority. Managing the client’s pain will help alleviate discomfort and allow for further assessment and treatment.
Choice C rationale
Ambulating in the hall is not appropriate for a client experiencing flank pain and nausea. It could exacerbate the symptoms.
Choice D rationale
Straining the urine is important for identifying any stones, but it is not the first priority. Pain management should be addressed first.
Correct Answer is B
Explanation
Choice A rationale
Notifying the charge nurse is important, but the priority action is to assess the client for any adverse effects of the medication error. This ensures the client’s immediate safety.
Choice B rationale
Checking the client’s vital signs is the priority action because it allows the nurse to assess for any immediate adverse effects of the medication error, such as changes in blood pressure or heart rate.
Choice C rationale
Filling out an occurrence report is necessary for documentation and institutional policy, but it is not the immediate priority. The client’s safety and assessment come first.
Choice D rationale
Documenting an objective description of the event in the client’s chart is important for medical records, but it should be done after assessing the client’s condition.
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