A nurse is caring for a client who is scheduled to receive intermittent peritoneal dialysis. Which of the following actions should the nurse take?
Weigh the client before and after each dialysis treatment.
Apply clean gloves when handling the bags of dialysate fluid.
Refrigerate the bags of dialysate fluid until ready for instillation.
Check peripheral circulation of the client's arms prior to treatment.
The Correct Answer is A
Choice A reason: This is the correct action, because weighing the client before and after each dialysis treatment can help monitor the fluid balance and the effectiveness of the dialysis.
Choice B reason: This is an incorrect action, because the nurse should apply sterile gloves when handling the bags of dialysate fluid to prevent infection.
Choice C reason: This is an incorrect action, because the bags of dialysate fluid should be warmed to body temperature before instillation to prevent hypothermia and abdominal cramps.
Choice D reason: This is an irrelevant action, because checking peripheral circulation of the client's arms has no relation to peritoneal dialysis, which involves the insertion of a catheter into the abdominal cavity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is an incorrect action, because covering the insertion site with a hydrocolloid dressing can prevent air from escaping and cause a subcutaneous emphysema, which is a complication of chest tube removal. The insertion site should be covered with a sterile gauze dressing and taped on three sides.
Choice B reason: This is an important action, but not the first one. The nurse should provide pain medication before removal, not immediately after, to reduce the discomfort and anxiety of the client.
Choice C reason: This is the correct action, because auscultating the lungs after removal can help assess the respiratory status and detect any signs of pneumothorax, such as diminished or absent breath sounds.
Choice D reason: This is an incorrect action, because delegating removal of the chest tube to an AP is beyond the scope of practice and can cause harm to the client. The removal of the chest tube should be performed by the nurse or the provider.
Correct Answer is C
Explanation
Choice A reason: A cholesterol level of 195 mg/dL is not an increased risk for atherosclerosis, because it is within the normal range of less than 200 mg/dL. Cholesterol is a type of fat that circulates in the blood and can contribute to plaque formation in the arteries.
Choice B reason: Elevated HDL levels are not an increased risk for atherosclerosis, because HDL stands for high-density lipoprotein, which is the "good" cholesterol that helps to remove excess cholesterol from the blood and prevent plaque formation in the arteries.
Choice C reason: Elevated LDL levels are an increased risk for atherosclerosis, because LDL stands for low-density lipoprotein, which is the "bad" cholesterol that can deposit in the arterial walls and cause plaque formation and narrowing of the arteries.
Choice D reason: A triglyceride level of 135 mg/dL is not an increased risk for atherosclerosis, because it is within the normal range of less than 150 mg/dL. Triglycerides are another type of fat that circulates in the blood and can contribute to plaque formation in the arteries.
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