A nurse is caring for a client during his first hemodialysis treatment. The client reports a headache, nausea, and is agitated. Which of the following complications should the nurse identify these findings as manifestations of?
Disequilibrium syndrome
Septicemia
Air embolism
Peritonitis
The Correct Answer is A
Choice A reason: Disequilibrium syndrome is characterized by headache, nausea, and agitation, which can occur during or after hemodialysis, especially in the first few sessions as the body adjusts to the treatment².
Choice B reason: Septicemia would typically present with fever, chills, and hypotension, not specifically headache and agitation².
Choice C reason: Air embolism is a rare complication that would present with sudden respiratory distress, chest pain, and possibly hypotension, not just headache and agitation².
Choice D reason: Peritonitis is associated with abdominal pain and tenderness, fever, and possibly altered bowel movements, not the symptoms described².
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:Placing the client in a sitting position helps to lower blood pressure by promoting venous return and is the first action to take in cases of autonomic dysreflexia²³.
Choice B reason:While examining for skin breakdown is important, it is not the first action to take when autonomic dysreflexia is suspected.
Choice C reason:Checking the bladder for distention is a critical step, but it should be done after positioning the client to address immediate blood pressure concerns.
Choice D reason:Checking for fecal impaction is also important but follows the initial step of positioning the client to manage blood pressure.
Correct Answer is ["35"]
Explanation
- Step 1: Identify the total volume to be administered. The nurse is scheduled to administer 840 mL of enteral nutrition over a 24-hour period.
- Step 2: Identify the total time over which the volume is to be administered. The total time is 24 hours.
- Step 3: Calculate the rate at which the infusion pump should be set. We can do this by dividing the total volume by the total time:
- Rate = Total Volume ÷ Total Time.
- Rate = 840 mL ÷ 24 hours.
- Calculating the division gives us: Rate = 35 mL/hr.
set the infusion pump to deliver 35 mL/hr.
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