A nurse is caring for a client receiving a hemodialysis treatment. Which of the following complications should the nurse recognize when the client becomes restless and reports nausea and headache?
Acute hemolysis
Disequilibrium syndrome
Septic shock
Air embolism
The Correct Answer is B
A. Acute hemolysis: While it is a complication of dialysis, it typically presents with back pain, dark red urine, and hypotension.
B. Disequilibrium syndrome: Caused by rapid removal of urea during dialysis, leading to cerebral edema. Early signs include nausea, headache, restlessness, and confusion.
C. Septic shock: Presents with hypotension, tachycardia, and signs of infection. Not the most likely with nausea and headache alone.
D. Air embolism: Presents with sudden chest pain, dyspnea, and hypotension; not typically with headache and restlessness alone.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Maintain adequate IV hydration: The first priority in major burns is fluid resuscitation due to massive fluid shifts and risk of hypovolemic shock.
B. Administer broad-spectrum antibiotics: Not a priority during the initial resuscitative phase. Infection control comes later unless signs of sepsis appear.
C. Give IV potassium chloride: Burn patients often experience hyperkalemia initially due to cell lysis; potassium is not given early.
D. Prepare intramuscular pain medications: IM route is avoided due to poor perfusion and risk of inadequate absorption in burn patients.
Correct Answer is D
Explanation
A. "A piece of healthy skin will be removed from an unburned area and grafted over the burned area.": This describes a skin graft, not escharotomy.
B. "This procedure involves placing the client into a Whirlpool tub and removing the dead tissue.": This describes hydrotherapy or wound debridement.
C. "Dead tissue will be non-surgically removed.": Describes enzymatic or mechanical debridement.
D. "Incisions will be made in the burnt tissues to improve circulation.": Escharotomy relieves pressure caused by tight, burned skin (eschar) to restore blood flow and prevent compartment syndrome.
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