A nurse is caring for a client on hemodialysis who complains of headache and restlessness. The client's blood pressure is elevated compared to baseline. Which of the following actions should the nurse take first?

Administer an analgesic for the headache.

Notify the healthcare provider about the blood pressure changes.

Assess the client's weight and fluid intake during the dialysis session.

Increase the dialysate solution flow rate to improve fluid removal.

Answer and Explanation

The Correct Answer is C

A)This statement is incorrect. Administering an analgesic for the headache may provide temporary relief, but it does not address the underlying issue of fluid overload and elevated blood pressure.

B) This statement is incorrect. Notifying the healthcare provider about the blood pressure changes is important, but assessing for fluid overload and taking appropriate actions should be the nurse's priority.

C) This statement is accurate. Headache and restlessness during hemodialysis, along with elevated blood pressure, may indicate fluid overload. The nurse should assess the client's weight and fluid intake during the dialysis session to determine if there is excessive fluid retention.

D) This statement is incorrect. Increasing the dialysate solution flow rate may not be appropriate without further assessment of the client's fluid status. It could worsen the fluid overload and further increase blood pressure.

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Correct Answer is C

Explanation

A) This statement is incorrect. Peritoneal dialysis does not require extended hospital stays, as it can be performed at home.

B) This statement is incorrect. While some modifications to daily activities may be necessary, peritoneal dialysis does not generally require clients to limit their daily activities or avoid physical exertion.

C) This statement is accurate. Peritoneal dialysis is a form of dialysis that can be performed by the client at home, allowing them to continue with their daily activities without the need for hospitalization or daily clinic visits.

D) This statement is incorrect. Peritoneal dialysis is performed by the client at home, not at the outpatient clinic every day. The client may visit the clinic for periodic follow-up and assessment, but the actual dialysis is performed at home.

A. Hemoglobin levels B. Platelet count C. Blood glucose levels D. Blood urea nitrogen (BUN) levels

Correct Answer is B

Explanation

A) This statement is incorrect. Monitoring hemoglobin levels is essential for clients with ESRD and during hemodialysis, but it is not directly related to the administration of heparin.

B) This statement is accurate. While a drop in platelet count is not uncommon during heparin administration, the nurse should closely monitor the client's platelet count to detect any significant changes or potential complications related to heparin-induced thrombocytopenia.

C) This statement is incorrect. Monitoring blood glucose levels is important, especially for clients with diabetes or those at risk of hypoglycemia during dialysis, but it is not specifically related to heparin administration.

D) This statement is incorrect. Monitoring blood urea nitrogen (BUN) levels is crucial for clients with ESRD, but it is not directly related to the administration of heparin during hemodialysis.

QUESTIONS

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A nurse is caring for a client on hemodialysis who complains of headache and restlessness. The client's blood pressure is elevated compared to baseline. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with end-stage renal disease (ESRD) who is starting peritoneal dialysis. The client expresses concerns about the impact on their daily activities. Which of the following responses by the nurse is appropriate?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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