A client on hemodialysis develops a sudden onset of chest pain and dyspnea. What is the nurse's priority action?
Administer a prescribed analgesic for pain relief.
Assess the client's blood pressure and heart rate.
Monitor the client's weight before and after dialysis.
Place the client in a semi-Fowler's position.
The Correct Answer is B
A. Incorrect. Administering a prescribed analgesic may be necessary, but it is not the priority when the client is experiencing sudden chest pain and dyspnea.
B. Correct. The sudden onset of chest pain and dyspnea can be indicative of potential complications, such as dialysis-related hypotension, cardiac issues, or fluid overload. Assessing the client's blood pressure and heart rate is the priority to identify any acute changes or abnormalities.
C. Incorrect. Monitoring the client's weight is important to assess fluid status, but it is not the immediate priority when the client presents with acute chest pain and dyspnea.
D. Incorrect. Placing the client in a semi-Fowler's position may be appropriate for respiratory distress, but the nurse should first assess the client's vital signs and overall condition before implementing positioning changes.
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Related Questions
Correct Answer is D
Explanation
A) This statement is incorrect. Hypercalcemia (elevated calcium levels) can be a concern in ESRD, but it is not the primary indication for initiating dialysis in this scenario. Pruritus is more commonly associated with uremia and high levels of other waste products.
B) This statement is incorrect. Hypervolemia (fluid overload) can be a concern in ESRD, but it is not the primary indication described in the scenario. The persistent pruritus is more likely related to uremia and the accumulation of toxins.
C) This statement is incorrect. Hyperkalemia (elevated potassium levels) is not the primary indication described in the scenario. While hyperkalemia may occur in ESRD, the primary concern leading to the need for dialysis in this case is the uremia and its associated symptoms.
D) Uremia, which is the accumulation of urea and other waste products in the blood, can lead to various complications, including pruritus. Dialysis helps remove these waste products from the bloodstream and may alleviate the itching associated with uremia.
Correct Answer is B
Explanation
A. Incorrect. Increasing the dialysate temperature can lead to vasodilation and potentially exacerbate hypotension during dialysis.
B. Correct. Limiting fluid removal during dialysis is essential to prevent excessive fluid loss, which can cause hypotension and potentially lead to intradialytic hypotension.
C. Incorrect. Encouraging a high-sodium diet is not the primary intervention to prevent dialysis-related hypotension. It may be recommended for some clients to manage hyponatremia, but fluid management is more critical.
D. Incorrect. Administering intravenous hypertonic saline during dialysis is not a routine intervention to prevent hypotension. It may be used in specific cases, but fluid management is the primary approach.
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