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 C
Explanation
Choice A rationale
Metabolic acidosis is incorrect. Metabolic acidosis is characterized by a low pH and low HCO₃ levels. In this case, the HCO₃ level is normal, which rules out metabolic acidosis.
Choice B rationale
Metabolic alkalosis is incorrect. Metabolic alkalosis is characterized by a high pH and high HCO₃ levels. In this case, the pH is low, and the HCO₃ level is normal, which rules out metabolic alkalosis.
Choice C rationale
Respiratory acidosis is correct. Respiratory acidosis is characterized by a low pH and high PaCO₂ levels. In this case, the pH is 7.24 (low), and the PaCO₂ is 53 (high), indicating respiratory acidosis. This condition occurs when there is an accumulation of CO₂ in the blood due to inadequate ventilation.
Choice D rationale
Respiratory alkalosis is incorrect. Respiratory alkalosis is characterized by a high pH and low PaCO₂ levels. In this case, the pH is low, and the PaCO₂ is high, which rules out respiratory alkalosis.
Correct Answer is C
Explanation
Choice A rationale
Osteoarthritis is not caused by inflammation that affects both joints and other body tissues. This description is more characteristic of rheumatoid arthritis, which is an autoimmune disease that causes systemic inflammation.
Choice B rationale
Osteoarthritis does not occur in phases with crystal deposits. This description is more characteristic of gout, which involves the deposition of urate crystals in joints and soft tissues.
Choice C rationale
Osteoarthritis is primarily due to the aging process and results in the disintegration of cartilage in a joint. This leads to pain, stiffness, and reduced joint function.
Choice D rationale
Osteoarthritis is not due to the loss of calcium in the bones. This description is more characteristic of osteoporosis, which is a condition that weakens bones and increases the risk of fractures.
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