A client on hemodialysis presents with a severe headache, confusion, and seizures. What action should the nurse take first?
Administer an antiepileptic medication.
Assess the client's blood glucose levels.
Document the findings and monitor the client.
Check the client's pre-dialysis weight.
The Correct Answer is B
A. Incorrect. While administering an antiepileptic medication may be necessary if the client is experiencing seizures, it is essential to identify the underlying cause first.
B. Correct. The client's severe headache, confusion, and seizures may be indicative of dialysis disequilibrium syndrome, which is a complication of rapid solute removal during hemodialysis. Hypoglycemia can also present with similar symptoms, so assessing blood glucose levels is crucial to differentiate between the two conditions.
C. Incorrect. Documenting the findings and monitoring the client's condition are important, but addressing the acute symptoms and potential cause should be the priority.
D. Incorrect. Checking the client's pre-dialysis weight is not the priority when the client is experiencing severe neurological symptoms. Immediate assessment and intervention are needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) This statement is accurate. Palpating for a thrill or vibration over the AV fistula site is a critical assessment to ensure proper functioning. A thrill indicates adequate blood flow through the fistula, which is essential for effective hemodialysis.
B) This statement is incorrect. Auscultating for bruits over the radial artery is not related to the AV fistula assessment. The bruit is the sound of blood flow in the fistula, which is best assessed directly over the fistula site.
C) This statement is incorrect. Checking for distal pulses in the lower extremities is not related to the assessment of an AV fistula. The AV fistula is typically created in the upper extremity.
D) This statement is incorrect. Assessing for swelling and tenderness in the neck is not related to the AV fistula assessment. Swelling and tenderness may be related to other issues but are not specific to AV fistula functioning.
Correct Answer is C
Explanation
A) This statement is incorrect. The catheter dressing should be changed regularly as per the healthcare provider's instructions, but it is not typically changed every week.
B) This statement is incorrect. The routine use of antibiotic ointment is not recommended, as it can lead to antibiotic resistance and is not necessary for all clients on peritoneal dialysis.
C) To reduce the risk of infection, the client should avoid touching the catheter site with clean hands. Maintaining proper hand hygiene is essential to prevent infection.
D) This statement is incorrect. Cleaning the catheter site with hydrogen peroxide is not recommended, as it can be too harsh and irritating to the skin. Instead, the site should be cleaned with mild soap and water or as instructed by the healthcare provider.
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