A nurse is caring for a client who becomes unresponsive. While administering CPR, which of the following actions should the nurse take?

Choice A reason: A blood pressure of 134/82 mm Hg is within the normal range and typically does not require immediate intervention. It is important to monitor blood pressure trends, but this value alone is not concerning.

Choice B reason: The correct answer is b because headache and restlessness can be signs of dialysis-related complications such as disequilibrium syndrome or fluid and electrolyte imbalances. These symptoms should be reported to the provider for further evaluation and management.

Choice C reason: A palpable thrill at the AV fistula access site indicates that the fistula is functioning properly. This is an expected finding and does not require intervention.

Choice D reason: A heart rate of 65 bpm is within the normal range for most adults and does not typically require immediate intervention unless associated with other symptoms or abnormalities.

Choice A reason: Providing a diet high in protein is not appropriate during the oliguric phase of acute kidney injury, as it can increase the workload on the kidneys and worsen kidney function. Protein intake should be carefully managed based on the client's condition.

Choice B reason: Ibuprofen is contraindicated in clients with acute kidney injury because it can further impair kidney function. Pain management should be approached with alternative medications that do not have nephrotoxic effects.

Choice C reason: The correct answer is c because monitoring intake and output hourly is crucial in managing acute kidney injury. Accurate measurement of fluid balance helps guide treatment decisions and prevent complications such as fluid overload or dehydration.

Choice D reason: Encouraging the client to consume at least 2 L of fluid daily is not appropriate in the oliguric phase, as the kidneys' ability to excrete fluids is impaired. Fluid intake should be carefully restricted and monitored to avoid fluid overload.