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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: This is an incorrect statement, because the client should not share razors with anyone, even if they are disposable. Razors can cause cuts and bleeding, which can transmit the HIV virus and other infections. The client should use their own personal hygiene items and dispose of them safely.

Choice B reason: This is the correct statement, because the client should clean bathroom surfaces with a bleach and water solution. Bleach is a disinfectant that can kill germs and prevent the spread of infections. The client should also wash their hands frequently and avoid contact with bodily fluids.

Choice C reason: This is an incorrect statement, because the client should not increase their intake of raw fruits and vegetables. Raw fruits and vegetables can contain bacteria, parasites, or pesticides, which can cause infections and complications in the client who has a weakened immune system. The client should wash and cook their fruits and vegetables thoroughly before eating them.

Choice D reason: This is an incorrect statement, because the client should not continue their hobby of gardening, even if they wear a mask. Gardening can expose the client to soil, dust, fungi, or insects, which can cause infections and allergies in the client who has a compromised immune system. The client should avoid activities that can increase their risk of infection.

A. Check and document the client's vital signs B. Ensure that the client's IV site uses a 22-gauge needle C. Verify that the blood type and Rh of the packed RBCs are checked by two nurses D. Obtain a bag of lactated Ringer's IV solution E. Provide the RN with tubing that has a filter

Correct Answer is ["A","C","E"]

Explanation

Choice A reason: Checking and documenting the client's vital signs is a correct action, because it provides a baseline for comparison and helps to monitor for any signs of adverse reactions to the transfusion.

Choice B reason: Ensuring that the client's IV site uses a 22-gauge needle is an incorrect action, because a larger gauge needle (18- or 20-gauge) is preferred for blood transfusions to prevent hemolysis of the RBCs.

Choice C reason: Verifying that the blood type and Rh of the packed RBCs are checked by two nurses is a correct action, because it is a standard safety procedure to prevent transfusion errors and ensure compatibility.

Choice D reason: Obtaining a bag of lactated Ringer's IV solution is an incorrect action, because only normal saline (0.9% sodium chloride) should be used as the IV solution for blood transfusions. Other solutions may cause hemolysis or clotting of the blood.

Choice E reason: Providing the RN with tubing that has a filter is a correct action, because a filter is required for blood transfusions to remove any clumps or debris from the blood.

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A nurse is caring for a client who is scheduled to receive intermittent peritoneal dialysis. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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