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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Assist the family to establish a daily routine: Establishing routines can provide structure, but it is more effective after the nurse has assessed the family’s current functioning and needs following the loss.
B. Refer the family to a grief support group: Referral to support groups is beneficial, but it is not the initial step. Understanding the family’s dynamics and coping capacity should precede external referrals.
C. Determine the roles of individual family members: Assessing each member’s role and function helps the nurse understand how the family is coping and identifies areas of strength and need. This assessment guides appropriate interventions and prioritizes support.
D. Encourage the family to assign specific tasks to individual family members: Assigning tasks is part of restoring structure, but it should follow an assessment of roles and capabilities to ensure tasks are appropriate and achievable.
Correct Answer is C
Explanation
Rationale:
A. Check the compatibility of cefazolin with the client's existing IV fluids: Compatibility is important to prevent precipitation or inactivation of the drug, but it should be done only after confirming the medication is safe for the client to receive.
B. Assess the IV for patency: Ensuring the IV line is patent is necessary before administration to avoid infiltration or extravasation, but it is not the first priority when preparing a first-time antibiotic dose.
C. Review the client's allergy history: Reviewing allergies is the first and most critical step, as cefazolin is a cephalosporin that can cause severe allergic reactions, particularly in clients with a history of beta-lactam (e.g., penicillin) allergy. Administering the drug without this check could cause life-threatening anaphylaxis.
D. Obtain the reconstituted antibiotic from the pharmacy: Securing the medication from the pharmacy is part of preparation, but this should only occur after confirming it is safe for the client to receive based on allergy status.
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