The nurse is administering intravenous (IV) fluids to a patient undergoing hemodialysis. Which action is most important for the nurse to take to ensure patient safety during the procedure?

Check the patient's blood pressure before and after the IV administration.

Ensure the dialysis access site is used for IV administration when possible.

Verify the correct fluid type and rate as per the physician's order.

Monitor for signs of infiltration or extravasation at the IV site.

Answer and Explanation

The Correct Answer is C

Choice A reason: Checking the patient's blood pressure before and after IV administration is important, but it is not the most critical action to ensure safety during the procedure.

Choice B reason: Ensuring the dialysis access site is used for IV administration when possible is not standard practice. The dialysis access site is typically reserved for dialysis treatments to prevent complications.

Choice C reason: Verifying the correct fluid type and rate as per the physician's order is the most important action. Ensuring the right fluid type and rate prevents potential complications such as fluid overload, electrolyte imbalances, and adverse reactions.

Choice D reason: Monitoring for signs of infiltration or extravasation at the IV site is important, but verifying the correct fluid type and rate takes precedence to prevent any errors in the initial setup.

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Correct Answer is D

Explanation

Choice A reason: Family history of common bile duct disorder is not a known trigger for irritable bowel syndrome (IBS). IBS is a functional gastrointestinal disorder with multifactorial causes, including but not limited to genetics, gut-brain axis, and environmental factors. Bile duct disorders and IBS have different pathophysiological mechanisms and are not directly linked.

Choice B reason: The frequent occurrence of blood in the stool is not a cause of IBS. Blood in the stool is more indicative of other gastrointestinal conditions such as inflammatory bowel disease (IBD), colorectal cancer, or haemorrhoids. IBS is characterized by abdominal pain, bloating, and changes in bowel habits without organic pathology such as bleeding.

Choice C reason: While there is some evidence suggesting that individuals with a family history of psychiatric disorders and food allergies may have a higher prevalence of IBS, it is not the main cause. These factors may contribute to the onset and exacerbation of symptoms but are part of a broader spectrum of triggers, including genetics, stress, and gut microbiota.

Choice D reason: Environmental and psychosocial factors are indeed associated with the onset of IBS. Factors such as stress, anxiety, depression, and traumatic life events can play a significant role in the development and exacerbation of IBS symptoms. Additionally, environmental factors like diet, infections, and changes in gut microbiota are known to influence IBS. This choice aligns with current evidence-based understanding of the condition.

A. Remind the patient that they will be responsible for caring for the ileostomy after discharge. B. Reassure the patient that this procedure will be reversed in a few months. C. Acknowledge the patient's reluctance and initiate discussion to explore their feelings. D. Discuss with the medical team during interdisciplinary rounds the need for a psychiatric referral.

Correct Answer is C

Explanation

Choice A reason: Reminding the patient that they will be responsible for caring for the ileostomy after discharge may increase their anxiety and reluctance. It does not address the underlying concerns or feelings.

Choice B reason: Reassuring the patient that the procedure will be reversed in a few months is not always accurate and may provide false hope. Each patient's situation is unique, and not all ileostomies are temporary.

Choice C reason: Acknowledging the patient's reluctance and initiating a discussion to explore their feelings is the most appropriate response. This approach allows the nurse to understand the patient's concerns, provide emotional support, and offer practical solutions to help the patient feel more comfortable with ostomy care.

Choice D reason: Discussing the need for a psychiatric referral during interdisciplinary rounds is not the immediate step. The nurse should first address the patient's feelings and concerns directly and provide support.

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The nurse is administering intravenous (IV) fluids to a patient undergoing hemodialysis. Which action is most important for the nurse to take to ensure patient safety during the procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with a new diagnosis of irritable bowel syndrome (IBS). The patient is upset and concerned about how they got IBS. What evidence-based information, related to the causes of IBS, will the nurse provide to this patient?

Correct Answer is D

Explanation

The nurse is caring for a patient with inflammatory bowel disease who has been discharged with an ileostomy. The patient expresses reluctance to participate in aspects of ostomy care. What is the nurse's most appropriate response to this observation?

Correct Answer is C

Explanation

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