A nurse is planning care for a client who is receiving hemodialysis. Which of the following actions should the nurse include in the plan of care?
Give an antibiotic 30 min before dialysis.
Check the vascular access site for bleeding after dialysis.
Rehydrate with dextrose 5% in water for orthostatic hypotension.
Withhold all medications until after dialysis.
The Correct Answer is B
A. Give an antibiotic 30 min before dialysis: Some antibiotics may require timing adjustments around dialysis, but this depends on the specific drug and provider orders. Administering antibiotics is not universally required before each dialysis session.
B. Check the vascular access site for bleeding after dialysis: Monitoring the vascular access site for bleeding, swelling, or infection is a critical safety measure after hemodialysis. Proper assessment helps prevent complications such as hemorrhage or thrombosis.
C. Rehydrate with dextrose 5% in water for orthostatic hypotension: Fluid administration during or after dialysis must be carefully managed due to the risk of fluid overload. Standard rehydration with dextrose 5% in water is not routinely recommended for hypotension after dialysis.
D. Withhold all medications until after dialysis: Not all medications should be withheld; some are given before or during dialysis depending on their pharmacokinetics and dialysis clearance. Blanket withholding of medications can be unsafe and may lead to untreated conditions.
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Related Questions
Correct Answer is C
Explanation
A. Remind the client to eat scheduled meals daily: Clients nearing the end of life often have a decreased appetite and may be unable or unwilling to eat. Forcing meals can cause discomfort and is not a priority at this stage.
B. Place the client in a supine position: Lying flat can increase the risk of aspiration and respiratory discomfort. Positioning the client for comfort, often semi-Fowler’s or side-lying, is preferred.
C. Offer the client a blanket to keep warm: Clients near the end of life may experience chills or cool extremities due to decreased circulation. Providing a blanket helps maintain comfort and dignity, which is a primary goal of end-of-life care.
D. Speak in a loud tone when addressing the client: Speaking loudly is unnecessary unless the client has hearing impairment. Communication should remain calm, gentle, and respectful to provide reassurance and maintain comfort.
Correct Answer is D
Explanation
Rationale:
A. "Your baby needs an IV because she is breathing slower than normal.": Severe dehydration is more likely to cause tachypnea rather than slower breathing, as the body attempts to compensate for metabolic acidosis.
B. "Your baby needs an IV because her heart rate is decreased.": Severe dehydration in infants usually results in tachycardia due to hypovolemia. A decreased heart rate may indicate impending cardiovascular collapse, which is a late and severe sign.
C. "Your baby needs an IV because her fontanels are bulging.": Bulging fontanels suggest increased intracranial pressure, not dehydration. Dehydration typically causes sunken fontanels due to decreased fluid volume.
D. "Your baby needs an IV because she is not producing tears.": Absence of tears during crying is a classic sign of significant dehydration in infants. This indicates reduced fluid volume and supports the need for IV therapy to restore hydration.
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