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 B
Explanation
A. Playing with a jump rope: Jump rope requires advanced gross motor coordination and balance, which typically develops around age 4–5 years. A 30-month-old is not developmentally ready for this activity.
B. Playing with a large plastic truck: Toddlers around 2–3 years enjoy manipulating large toys such as trucks, cars, or blocks. This play supports fine and gross motor skills, hand-eye coordination, and imaginative exploration appropriate for their developmental stage.
C. Playing with dress-up clothes: Pretend or dress-up play becomes more common around age 3–4 years, as symbolic thinking and role-playing abilities develop. A 30-month-old may begin simple pretend play but usually engages in more concrete, manipulative play.
D. Playing with an imaginary friend: Engaging in complex imaginative play, such as interacting with an imaginary friend, usually emerges around age 3–4 years, reflecting more advanced cognitive and social development than expected at 30 months.
Correct Answer is C
Explanation
A. "You will be given access to the medical records of every client in the facility.": Access to electronic medical records is restricted based on the nurse’s role and need-to-know basis to protect client confidentiality. Nurses only view records of clients under their care.
B. "You will be asked to change your password once per year.": Most facilities require more frequent password changes, often every 60–90 days, to maintain system security. Annual changes alone are insufficient for protecting client data.
C. "Information Technology will install a firewall to secure client information.": Firewalls and other cybersecurity measures help protect electronic health information from unauthorized access. Including this ensures nurses understand that the system has built-in technical safeguards for privacy and security.
D. "Documentation of sensitive material is performed by the charge nurse.": All licensed nurses are responsible for accurate, complete, and timely documentation of client care, including sensitive material. Responsibility is not limited to the charge nurse.
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