A nurse is caring for a client on hemodialysis who complains of headache and restlessness. The client's blood pressure is elevated compared to baseline. Which of the following actions should the nurse take first?
Administer an analgesic for the headache.
Notify the healthcare provider about the blood pressure changes.
Assess the client's weight and fluid intake during the dialysis session.
Increase the dialysate solution flow rate to improve fluid removal.
The Correct Answer is C
A)This statement is incorrect. Administering an analgesic for the headache may provide temporary relief, but it does not address the underlying issue of fluid overload and elevated blood pressure.
B) This statement is incorrect. Notifying the healthcare provider about the blood pressure changes is important, but assessing for fluid overload and taking appropriate actions should be the nurse's priority.
C) This statement is accurate. Headache and restlessness during hemodialysis, along with elevated blood pressure, may indicate fluid overload. The nurse should assess the client's weight and fluid intake during the dialysis session to determine if there is excessive fluid retention.
D) This statement is incorrect. Increasing the dialysate solution flow rate may not be appropriate without further assessment of the client's fluid status. It could worsen the fluid overload and further increase blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
A) This statement is incorrect. Dialysis does not restore normal kidney function. Instead, it serves as a substitute for impaired kidney function, helping to maintain fluid and electrolyte balance.
B) This statement is incorrect. Dialysis is not a surgical procedure to transplant a healthy kidney. Kidney transplantation is a separate procedure that involves replacing a damaged kidney with a healthy one from a living or deceased donor.
C) This statement is incorrect. Dialysis may help manage complications of CKD and prolong life, but it does not prevent the progression of the underlying kidney disease. CKD is a chronic and progressive condition that may eventually require dialysis or kidney transplantation.
D) This statement is accurate. Dialysis is the process of removing waste products, excess fluids, and toxins from the blood when the kidneys are no longer able to perform these functions adequately.
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.