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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Limiting dietary fiber is incorrect for IBS, as soluble fiber helps regulate bowel movements. This indicates a need for further teaching, making it the correct statement, as it contradicts the nurse’s instructions to include fiber for IBS symptom management.
Choice B reason: Drinking 8 to 10 cups of fluid daily supports hydration and bowel function in IBS, showing understanding. This is incorrect, as it aligns with the nurse’s teaching, unlike the fiber limitation statement requiring further client education.
Choice C reason: Eating regular meals and chewing well stabilizes digestion in IBS, reflecting correct understanding. This is incorrect, as it aligns with the nurse’s instructions, unlike the fiber limitation statement that indicates a need for further teaching.
Choice D reason: Taking prescribed medications to regulate bowel patterns is appropriate for IBS management, showing understanding. This is incorrect, as it aligns with the nurse’s teaching, unlike the incorrect fiber limitation statement needing further client instruction.
Correct Answer is A
Explanation
Choice A reason: Hypercalcemia shortens the QT interval on ECG due to accelerated cardiac repolarization. This aligns with electrolyte-related cardiac monitoring, making it the correct change the nurse would recognize as indicating possible hypercalcemia in the client’s electrocardiography assessment.
Choice B reason: Inverted T waves suggest ischemia or hypokalemia, not hypercalcemia, which shortens the QT interval. This is incorrect, as it doesn’t align with the nurse’s expected ECG change for hypercalcemia compared to the characteristic shortened QT interval.
Choice C reason: Prominent U waves are associated with hypokalemia, not hypercalcemia, which affects the QT interval. Shortened QT is correct, making this incorrect, as it’s unrelated to the nurse’s monitoring for hypercalcemia’s ECG changes in the client.
Choice D reason: Absent P waves indicate atrial fibrillation, not hypercalcemia, which shortens the QT interval. This is incorrect, as it doesn’t reflect the nurse’s anticipated ECG change for hypercalcemia, unlike the characteristic shortened QT interval in the client’s monitoring.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
