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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. Applying pressure to the bleeding site is the first action to control the bleeding and prevent excessive blood loss.
B. Incorrect. Elevating the arm above heart level may not be effective in controlling bleeding from the access site and could cause unnecessary discomfort.
C. Incorrect. Administering a prescribed antiplatelet medication is not the first action to take when the client experiences bleeding from the access site, as it may further increase bleeding risk.
D. Incorrect. While checking the client's platelet count is important, it is not the first action to address active bleeding. Applying pressure to the bleeding site takes priority to control the bleeding.
QUESTIONS
Correct Answer is A
Explanation
A) This statement is accurate. Hypertonic dialysate has a higher concentration of glucose, which results in increased fluid removal from the client's peritoneal cavity. This type of dialysate is often used for more effective ultrafiltration.
B) This statement is incorrect. Infusing hypertonic dialysate does not result in decreased urine output. Peritoneal dialysis is a process of exchanging fluids and waste products through the peritoneal membrane, but it does not directly affect urine production.
C) This statement is incorrect. Infusing hypertonic dialysate would not lead to hydration overload, as it causes fluid to be removed from the body.
D) This statement is incorrect. Hypertonic dialysate would not cause hypotension. In fact, it may lead to a decrease in blood pressure due to fluid removal, but it would not be considered a primary cause of hypotension.
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