The newly licensed RN overhears two nurses talking in the elevator about a client who will lose her leg because of negligence of the staff. Which action by the newly licensed RN would be implemented first?

Choice A reason: Monitoring is important but doesn’t address the urgency of headache, nausea, and restlessness, suggesting disequilibrium syndrome. Notifying the provider is critical, making this incorrect, as it delays the nurse’s priority action to manage a serious post-dialysis complication.

Choice B reason: Elevating the head of the bed may help comfort but doesn’t treat potential disequilibrium syndrome indicated by headache and restlessness. Notifying the provider is urgent, making this incorrect, as it’s less critical than the nurse’s need to report symptoms.

Choice C reason: Assessing the fistula site is routine but unrelated to headache and nausea, which suggest a neurological issue. Notifying the provider takes precedence, making this incorrect, as it’s not the priority compared to addressing potential post-dialysis complications.

Choice D reason: Notifying the provider is the priority for headache, nausea, and restlessness post-hemodialysis, as these suggest disequilibrium syndrome, a serious complication. This aligns with dialysis care protocols, making it the correct action for the nurse to take immediately.

Choice A reason: Sitting upright improves breathing but doesn’t address the critical hypoxia indicated by 85% pulse oximetry. Applying oxygen directly corrects low oxygen levels, making this secondary and incorrect compared to the nurse’s priority of ensuring adequate oxygenation in a heart failure exacerbation.

Choice B reason: Calling for intubation anticipates worsening but is premature without first addressing hypoxia with oxygen. Applying oxygen is the immediate need, making this incorrect, as it bypasses the initial step of improving oxygenation in the client with severe respiratory distress.

Choice C reason: Preparing for a Foley catheter anticipates diuresis but doesn’t address the urgent hypoxia at 85% oxygen saturation. Applying oxygen is critical, making this incorrect, as it delays the primary intervention needed to stabilize the client’s respiratory status in heart failure.

Choice D reason: Applying oxygen is the first action to correct hypoxia (pulse oximetry 85%), improving tissue oxygenation in heart failure exacerbation. This aligns with acute care priorities, making it the correct intervention to address the client’s immediate respiratory distress and low oxygen saturation effectively.