The client receiving hemodialysis is complaining of being dizzy and light-headed. Which action should the nurse implement first?
Obtain vital signs
Bolus the client with 1000 m of normal saline
Turn off the dialysis machine immediately
Notify the health care provider as soon as possible
The Correct Answer is A
A. Obtain vital signs: Dizziness and lightheadedness during dialysis suggest hypotension, a common complication. The nurse should first assess vital signs to determine the severity before taking further action.
B. Bolus the client with 1000 mL of normal saline: If the client is hypotensive, a smaller fluid bolus (e.g., 250–500 mL) would be more appropriate.
C. Turn off the dialysis machine immediately: Stopping dialysis abruptly may cause fluid overload and other complications. The rate may need adjustment but not immediate cessation.
D. Notify the health care provider as soon as possible: While important, assessing the client’s current status is the priority before contacting the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}
Explanation
Respiratory acidosis- Due to opioid-induced respiratory depression (hypoventilation, CO₂ retention). Phlebitis- Due to IV therapy (15g IV and 0.9% NS at 150mL/hr), increasing the risk of vein irritation and inflammation.
Incorrect answers:
- Metabolic alkalosis: typically occurs due to vomiting or excessive bicarbonate intake.
- Hypervolemia: The client is receiving IV fluids, but there is no evidence of fluid overload.
- Osteomyelitis: Infection of the bone; not a direct risk in this scenario.
Correct Answer is B
Explanation
A. Milk and organ meats. These foods do not contain excessive sodium.
B. Cheese, lunch meats, and canned vegetables: These foods are high in sodium, which can worsen hypernatremia by increasing serum sodium levels. Processed meats and canned vegetables contain excess salt and preservatives.
C. Alcohol and fried foods. Alcohol can cause dehydration, but not necessarily high sodium levels.
D. Green leafy vegetables and salt substitutes. Green leafy vegetables are low in sodium, and some salt substitutes contain potassium, not sodium.
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