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 A
Explanation
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.
Correct Answer is B
Explanation
A. Provide water for a client diagnosed with chronic kidney disease: Fluid intake must be controlled in CKD. A nurse should determine if water intake is appropriate.
B. Instruct the client on appropriate fluid restrictions: Client education is a nursing responsibility and cannot be delegated to a UAP. The nurse should educate clients on fluid restrictions in conditions like chronic kidney disease (CKD) to prevent fluid overload and electrolyte imbalances.
C. Measure the client’s output from the indwelling catheter: This task can be delegated to a UAP.
D. Record the client’s intake and output in the EMR: UAPs can record I&O but cannot interpret the data.
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