A client with chronic kidney disease being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious, and the nurse suspects air embolism. What are the priority nursing actions? (Select all that apply)

Administer oxygen to the client.

Continue dialysis at a slower rate after checking the lines for air.

Notify the primary health care provider (PHCP) and Rapid Response Team.

Stop dialysis, and turn the client on the left side with head lower than feet.

Bolus the client with 500 mL of normal saline to break up the air embolus.

Answer and Explanation

Correct Answer : A,C,D

Choice A reason: Administering oxygen improves oxygenation in air embolism, addressing hypoxia from chest pain and shortness of breath. This aligns with emergency dialysis protocols, making it a correct priority action the nurse would take to stabilize the client’s condition.

Choice B reason: Continuing dialysis, even slowly, risks worsening air embolism by introducing more air. Stopping dialysis is critical, making this incorrect, as it’s unsafe compared to the nurse’s priority of halting the procedure to prevent further embolism complications.

Choice C reason: Notifying the provider and Rapid Response Team ensures rapid intervention for air embolism, a life-threatening dialysis complication. This aligns with emergency protocols, making it a correct priority action the nurse would take to manage the client’s acute condition.

Choice D reason: Stopping dialysis and positioning the client on the left side with head down traps air in the right atrium, preventing pulmonary embolism. This is a standard intervention, making it a correct priority action for the nurse to address air embolism.

Choice E reason: Bolusing 500 mL saline doesn’t break up air emboli and risks fluid overload in kidney disease. Oxygen administration is appropriate, making this incorrect, as it’s ineffective compared to the nurse’s priority actions for managing air embolism.

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Correct Answer is D

Explanation

Choice A reason: Hypertension and tachycardia may occur in dialysis but aren’t specific to disequilibrium syndrome, which causes neurological symptoms. Headache and twitching are key, making this incorrect, as it’s less precise than the nurse’s expected manifestations of disequilibrium syndrome.

Choice B reason: Hypotension may occur in dialysis, but bradycardia and hypothermia aren’t typical of disequilibrium syndrome, which affects the brain. Deteriorating consciousness is correct, making this incorrect, as it doesn’t align with the nurse’s assessment for this complication.

Choice C reason: Restlessness and weakness are vague and less specific than headache and twitching, which indicate cerebral edema in disequilibrium syndrome. This is incorrect, as it’s not the primary manifestation the nurse would assess in the dialysis client.

Choice D reason: Headache, deteriorating consciousness, and twitching indicate disequilibrium syndrome due to rapid osmotic shifts during hemodialysis. This aligns with neurological assessment, making it the correct set of manifestations the nurse would monitor in the client at risk.

A. Coffee. B. Chocolate. C. Peppermint. D. Nonfat milk. E. Fried chicken. F. Scrambled eggs.

Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason: Coffee, caffeinated or decaf, relaxes the esophageal sphincter and irritates the mucosa, worsening GERD. This aligns with dietary restrictions, making it a correct substance the nurse would teach the client to avoid to prevent GERD symptom exacerbation.

Choice B reason: Chocolate contains methylxanthines and fat, relaxing the esophageal sphincter and triggering GERD symptoms. This aligns with GERD dietary guidelines, making it a correct item the nurse would include for the client to avoid to reduce reflux.

Choice C reason: Peppermint relaxes the lower esophageal sphincter, increasing acid reflux in GERD. This aligns with dietary teaching, making it a correct substance the nurse would advise the client to avoid to minimize GERD symptom flare-ups effectively.

Choice D reason: Nonfat milk is less likely to trigger GERD, as high-fat dairy worsens reflux. Coffee is a stronger trigger, making this incorrect, as it’s not a primary substance the nurse would include on the GERD avoidance list.

Choice E reason: Fried chicken, high in fat, delays gastric emptying and exacerbates GERD symptoms. This aligns with dietary restrictions, making it a correct item the nurse would teach the client to avoid to prevent GERD symptom exacerbation.

Choice F reason: Scrambled eggs are low-fat and unlikely to trigger GERD compared to chocolate or coffee. This is incorrect, as it’s not a primary substance the nurse would include on the list of items to avoid for GERD management.

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A client with chronic kidney disease being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious, and the nurse suspects air embolism. What are the priority nursing actions? (Select all that apply)

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Naxlex Comprehensive Predictor Exams

The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse would assess the client during dialysis for which associated manifestations?

Correct Answer is D

Explanation

The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items would the nurse include on this list? (Select all that apply)

Correct Answer is ["A","B","C","E"]

Explanation

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