The nurse is delivering care to a dialysis client who received epoetin alfa during the previous visit. Which nursing intervention is most important during this treatment?
1. Ensuring that the client understands the indications and expected outcomes of epoetin alfa therapy
2. Ensuring that sufficient water is removed during dialysis, based on body weight
3. Ensuring that the shunt is appropriately cleaned and dressed after the treatment
4. Ensuring that the client receives sufficient heparin after the day's dialysis is complete
Correct Answer: 4
Rationale 1: The client would have been informed about the purpose and outcomes expected from epoetin alfa at the previous visit.
Rationale 2: Monitoring the amount of water removed is important during all dialysis treatments, but there is no increased importance after administration of epoetin alfa.
Rationale 3: Aseptic management of the shunt is important before, during, and after all treatments, but there is no increased importance after administration of epoetin alfa.
Rationale 4: The client is at great risk for clotting of the shunt because of increased RBC values.
Global Rationale: The client is at great risk for clotting of the shunt because of increased RBC values. The client would have been informed about the purpose and outcomes expected from epoetin alfa at the previous visit. Monitoring the amount of water removed is important during all dialysis treatments, but there is no increased importance after administration of epoetin alfa. Aseptic management of the shunt is important before, during, and after all treatments, but there is no increased importance after administration of epoetin alfa.
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