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.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: This is an incorrect action, because instructing the client to blink several times after instillation of the medication can cause the medication to drain out of the eye and reduce its effectiveness.
Choice B reason: This is a correct action, but not the best one. Asking the client to look straight ahead during instillation of the medication can help the nurse to aim the drop accurately and avoid touching the eye with the dropper.
Choice C reason: This is the best action, because applying pressure to the bridge of the nose after instillation of the medication can prevent the medication from entering the systemic circulation and causing adverse effects, such as bradycardia, hypotension, or bronchospasm.
Choice D reason: This is an incorrect action, because placing each drop of the medication directly on to the client's cornea can cause irritation, injury, or infection to the eye. The medication should be placed in the lower conjunctival sac of the eye.
Correct Answer is D
Explanation
Choice A reason: This is a dangerous action, because recapping the needle on the syringe can increase the risk of needlestick injuries and bloodborne infections.
Choice B reason: This is an unnecessary action, because the client may be able to self-administer insulin injections with proper education and supervision.
Choice C reason: This is an inappropriate action, because the syringe should not be disposed of in the bathroom trash can, which is not a safe or sanitary place for sharps waste.
Choice D reason: This is the correct action, because placing the syringe in a puncture-proof disposal container can prevent accidental injuries and infections, and comply with the local regulations for sharps disposal.
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