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.

Answer and Explanation

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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Correct Answer is C

Explanation

Rationale:

A. Tetracycline 200 mg PO: This prescription is incomplete because it does not specify the frequency or duration of administration, making it unclear how the medication should be given safely.

B. Cimetidine PO twice daily: The prescription lacks the dosage strength in milligrams, which is essential for accurate administration and safe dosing.

C. Digoxin 0.25 mg PO daily: This prescription includes the medication name, dosage, route, and frequency, providing all essential components needed for safe administration.

D. Epoetin alfa 150 units/kg three times weekly: While it includes dose and frequency, it does not specify the route (subcutaneous or IV), which is required to complete the prescription safely.

A. Discuss the client's preferences for determining a repositioning schedule. B. Evaluate the client's ability to help with repositioning C. Raise the side rails of the clients bed during repositioning. D. Reposition the client with the assistive devices

Correct Answer is B

Explanation

Rationale:

A. Discuss the client's preferences for determining a repositioning schedule: While involving the client in care planning is important, the schedule for repositioning is primarily determined by clinical needs to prevent complications such as pressure injuries, not solely by preference.

B. Evaluate the client's ability to help with repositioning: Assessing the client’s strength, mobility, and coordination after a stroke determines the level of assistance and equipment required. This ensures safety for both the client and the nurse during repositioning.

C. Raise the side rails of the client’s bed during repositioning: Side rails can create entrapment hazards if used incorrectly and should not be relied upon during repositioning. Their purpose is more for safety positioning after the move, not as a primary tool during the maneuver.

D. Reposition the client with the assistive devices: Assistive devices should be used if needed, but this step follows an assessment of the client’s capabilities. Selecting equipment without first evaluating the client may lead to unnecessary interventions.

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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?

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Naxlex Comprehensive Predictor Exams

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