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 D
Explanation
Choice A reason: This is an important action, but not the first one. The nurse should first address the client's comfort and inflammation before teaching them how to use the eye drops.
Choice B reason:Option B (warm compresses)is a key intervention for blepharitis to improve meibomian gland function and reduce crusting. However, assessment (Option D) must precede treatment to ensure no contraindications (e.g., corneal abrasion) and tailor care appropriately.
Choice C reason: This is a helpful action, but not the first one. The nurse should first apply warm compresses to the affected eye, and then dim the lights to reduce the sensitivity and pain.
Choice D reason:Thefirst stepin the nursing process isassessment. Even with a diagnosis of blepharitis, the nurse mustinspect the eyesto evaluate the current severity, presence of drainage (e.g., purulent vs. serous), redness, or signs of secondary infection (e.g., bacterial involvement). This informs subsequent interventions.
Correct Answer is A
Explanation
Choice A reason: This is a correct statement, because checking the heart rate each day can help monitor the function and effectiveness of the pacemaker, and detect any signs of malfunction, such as bradycardia, tachycardia, or irregular rhythm.
Choice B reason: This is an incorrect statement, because the client still needs to take the antihypertensive medications as prescribed, even with a pacemaker. The pacemaker regulates the heart rate, but does not control the blood pressure, which can be affected by other factors, such as stress, diet, or kidney function.
Choice C reason: This is an incorrect statement, because the client should avoid stretching the arms above the head for the first few weeks after the pacemaker insertion, as it can cause dislodgment or damage to the pacemaker leads. The client should limit the arm movements and activities until the incision site heals and the provider approves.
Choice D reason: This is an incorrect statement, because the client can stand in front of a microwave oven without any risk, as long as the oven is in good working condition and does not leak radiation. The modern microwave ovens and pacemakers are designed to prevent any interference or damage. However, the client should avoid close contact with other sources of electromagnetic fields, such as metal detectors, cell phones, or MRI machines.
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