A client on hemodialysis reports feeling lightheaded and dizzy during the procedure. Which of the following actions should the nurse take first?
Increase the rate of fluid removal during dialysis.
Administer an antihypertensive medication.
Assess the client's blood pressure and pulse rate.
Elevate the client's legs to promote blood flow.
The Correct Answer is C
A) This statement is incorrect. Increasing the rate of fluid removal during dialysis may worsen the client's symptoms of lightheadedness and dizziness, as it can lead to further drops in blood pressure.
B) This statement is incorrect. Administering an antihypertensive medication is not appropriate in this situation, as the client is experiencing symptoms of low blood pressure, not high blood pressure.
C) This statement is accurate. Feeling lightheaded and dizzy during hemodialysis may be a sign of hypotension (low blood pressure), and the nurse should assess the client's blood pressure and pulse rate to determine if intervention is needed.
D) This statement is incorrect. Elevating the client's legs may promote blood flow, but it does not address the immediate issue of lightheadedness and dizziness. Assessing the client's blood pressure and pulse rate is the priority to determine the appropriate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect. Collecting a sample of the effluent for culture and sensitivity testing may be necessary, but notifying the healthcare provider about the finding should be done first.
B. Incorrect. Stopping the exchange immediately may be necessary in some cases, but the nurse should first communicate the finding to the healthcare provider for further assessment and guidance.
C. Correct. Cloudy dialysate effluent may indicate peritonitis, an infection of the peritoneal cavity, which requires immediate attention and treatment by the healthcare provider.
D. Incorrect. Encouraging the client to perform another exchange without further assessment can potentially exacerbate any underlying issue causing the cloudy effluent.
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.
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