A nurse is caring for a client on hemodialysis. The client reports feeling dizzy and weak during the procedure. Which intervention should the nurse implement first?
Check the client's blood pressure and pulse rate.
Administer an antiemetic medication.
Increase the rate of fluid removal during dialysis.
Elevate the client's legs to promote blood flow.
The Correct Answer is A
A) The client's symptoms of dizziness and weakness may indicate hypotension (low blood pressure). The nurse should first check the client's blood pressure and pulse rate to assess for hypotension before implementing further interventions.
B) This statement is incorrect. Administering an antiemetic medication would not address the reported symptoms of dizziness and weakness, which may be related to changes in blood pressure.
C) This statement is incorrect. Increasing the rate of fluid removal during dialysis may exacerbate the client's symptoms of dizziness and weakness and may lead to hypotension (low blood pressure).
D) This statement is incorrect. Elevating the client's legs may help improve blood flow, but it does not address the underlying cause of the reported symptoms. The nurse should first check the client's blood pressure and pulse rate to assess for hypotension before implementing further interventions.
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Related Questions
Correct Answer is D
Explanation
A) This statement is incorrect. Hypokalemia (low potassium levels) is not an indication for initiating dialysis. In AKI, electrolyte imbalances can occur, but hyperkalemia is more likely due to impaired kidney function.
B) This statement is incorrect. Hyponatremia (low sodium levels) is not a primary indication for initiating dialysis in AKI. It can occur due to fluid shifts, but the primary concern in AKI is the accumulation of waste products like urea, leading to uremia.
C) This statement is incorrect. Hypernatremia (high sodium levels) is not a primary indication for initiating dialysis in AKI. Hypernatremia is rare in AKI and usually occurs when there is a significant loss of free water compared to sodium intake.
D) Uremia, which is characterized by elevated levels of urea and other waste products in the blood, is a critical indication for initiating dialysis in clients with acute kidney injury. Dialysis helps remove these toxic substances from the bloodstream.
Correct Answer is B
Explanation
A) This statement is incorrect. Monitoring hemoglobin levels is essential for clients with ESRD and during hemodialysis, but it is not directly related to the administration of heparin.
B) This statement is accurate. While a drop in platelet count is not uncommon during heparin administration, the nurse should closely monitor the client's platelet count to detect any significant changes or potential complications related to heparin-induced thrombocytopenia.
C) This statement is incorrect. Monitoring blood glucose levels is important, especially for clients with diabetes or those at risk of hypoglycemia during dialysis, but it is not specifically related to heparin administration.
D) This statement is incorrect. Monitoring blood urea nitrogen (BUN) levels is crucial for clients with ESRD, but it is not directly related to the administration of heparin during hemodialysis.
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