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 ["C","F"]

Explanation

Choice A reason: Red meat is not high in potassium, so it’s safe with potassium-sparing diuretics. Citrus fruits, high in potassium, risk hyperkalemia, making this incorrect, as it’s not a food the nurse would teach the client to avoid or use cautiously.

Choice B reason: Bread has low potassium content and is safe with potassium-sparing diuretics. Salt substitutes containing potassium are riskier, making this incorrect, as it’s not a food the nurse would include in teaching for cautious use with the diuretic.

Choice C reason: Citrus fruits, like oranges, are high in potassium, risking hyperkalemia with potassium-sparing diuretics. This aligns with dietary teaching, making it a correct food the nurse would teach the client to avoid or use cautiously to prevent electrolyte imbalance.

Choice D reason: Cereal is generally low in potassium unless fortified, not requiring caution with potassium-sparing diuretics. Citrus fruits are a concern, making this incorrect, as it’s not a primary food the nurse would teach the client to limit in the diet.

Choice E reason: Eggs are low in potassium and safe with potassium-sparing diuretics. Salt substitutes pose a hyperkalemia risk, making this incorrect, as it’s not a food the nurse would include in teaching for cautious use in the client’s dietary plan.

Choice F reason: Salt substitutes often contain potassium chloride, increasing hyperkalemia risk with potassium-sparing diuretics. This aligns with dietary education, making it a correct item the nurse would teach the client to avoid or use cautiously to prevent complications.

A. “The operating room is prepared; let’s not keep the surgeon waiting.” B. “You have the right to cancel surgery, but it could be weeks before you are rescheduled.” C. “You sound frightened; tell me what you are thinking.” D. “Your preoperative medications will have you feeling more relaxed in a minute, it will be fine.”

Correct Answer is C

Explanation

Choice A reason: Pressuring the patient to proceed disregards her autonomy and right to revoke consent. Exploring her concerns respects her decision, making this incorrect, as it dismisses the patient’s expressed wish to cancel the mitral valve replacement surgery during transport.

Choice B reason: Highlighting rescheduling delays may coerce the patient, undermining her right to refuse. Addressing her fears validates her feelings, making this incorrect, as it prioritizes logistics over the patient’s autonomy and emotional state during the surgical consent process.

Choice C reason: Asking about the patient’s thoughts acknowledges her fear and respects her right to revoke consent, facilitating open communication. This aligns with ethical nursing practice, making it the correct response to support the patient’s decision regarding mitral valve replacement surgery.

Choice D reason: Dismissing the patient’s refusal with reassurance about medications ignores her autonomy and consent rights. Exploring her concerns is more appropriate, making this incorrect, as it fails to address the patient’s explicit wish to cancel the surgery during transport.

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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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In collaboration with the registered dietitian nutritionist (RDN), which foods will the nurse teach a client who is taking a potassium-sparing diuretic to avoid or use cautiously? (Select all that apply)

Correct Answer is ["C","F"]

Explanation

During transport to the operating room for mitral valve replacement, a patient with a signed consent form says that she does not want to go through with the surgery and asks to be returned to her room. What is the best response from the nurse?

Correct Answer is C

Explanation

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