The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action?

Monitor the client.

Elevate the head of the bed.

Assess the fistula site and dressing.

Notify the primary health care provider (PHCP).

Answer and Explanation

The Correct Answer is D

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.

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Correct Answer is C

Explanation

Choice A reason: Seizure precautions are relevant but secondary to establishing IV access for antihypertensive administration in hypertensive crisis. Starting an IV enables immediate treatment, making this incorrect, as it delays the critical intervention needed to lower the client’s dangerously high blood pressure.

Choice B reason: Instructing to report vision changes monitors complications but doesn’t address the urgent need to lower blood pressure. IV access facilitates medication delivery, making this incorrect, as it postpones the primary action for managing the client’s hypertensive crisis effectively.

Choice C reason: Hypertensive crisis can cause severe headache, risk for stroke, pulmonary edema, and difficulty breathing. Elevating the HOB improves cerebral perfusion, reduces intracranial pressure, and eases breathing. This is an immediate, noninvasive, airway/circulation-supportive intervention.

Choice D reason: Needed for IV antihypertensive administration, but initial safety and circulation support (C) takes priority before establishing access.

A. “The operating room is prepared; let’s not keep the surgeon waiting.” B. “You have the right to cancel surgery, but it could be weeks before you are rescheduled.” C. “You sound frightened; tell me what you are thinking.” D. “Your preoperative medications will have you feeling more relaxed in a minute, it will be fine.”

Correct Answer is C

Explanation

Choice A reason: Pressuring the patient to proceed disregards her autonomy and right to revoke consent. Exploring her concerns respects her decision, making this incorrect, as it dismisses the patient’s expressed wish to cancel the mitral valve replacement surgery during transport.

Choice B reason: Highlighting rescheduling delays may coerce the patient, undermining her right to refuse. Addressing her fears validates her feelings, making this incorrect, as it prioritizes logistics over the patient’s autonomy and emotional state during the surgical consent process.

Choice C reason: Asking about the patient’s thoughts acknowledges her fear and respects her right to revoke consent, facilitating open communication. This aligns with ethical nursing practice, making it the correct response to support the patient’s decision regarding mitral valve replacement surgery.

Choice D reason: Dismissing the patient’s refusal with reassurance about medications ignores her autonomy and consent rights. Exploring her concerns is more appropriate, making this incorrect, as it fails to address the patient’s explicit wish to cancel the surgery during transport.

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The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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