a client with chronic kidney disease is receiving hemodialysis what is the nurses priority assessment following dialysis
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Nursing Elites

HESI RN

HESI 799 RN Exit Exam Capstone

1. After receiving hemodialysis, what is the nurse's priority assessment for a client with chronic kidney disease?

Correct answer: A

Rationale: The correct answer is to monitor the client's potassium level. During hemodialysis, there is a risk of potassium shifting, which can lead to life-threatening arrhythmias if not properly managed. Assessing the potassium level is crucial to prevent complications. While assessing blood pressure, checking hemoglobin and hematocrit levels, and monitoring for signs of infection are important aspects of care for a client with chronic kidney disease, monitoring potassium levels takes precedence due to its immediate life-threatening potential post-dialysis.

2. A female client taking prednisone reports feeling tired after stopping the corticosteroid abruptly. What is the priority nursing intervention?

Correct answer: C

Rationale: The correct answer is to palpate the abdomen. When a client abruptly stops taking prednisone, there is a risk of adrenal insufficiency, which can present with symptoms like fatigue. Palpating the abdomen is crucial to assess for signs of adrenal crisis, such as abdominal pain, which can indicate severe adrenal insufficiency. Auscultating breath sounds (Choice A) and observing the skin for bruising (Choice D) are not the priority interventions in this situation. While measuring vital signs (Choice B) is important, palpating the abdomen takes precedence in this case to assess for potential adrenal insufficiency.

3. A client recovering from a stroke is demonstrating slurred speech. What action should the nurse take?

Correct answer: C

Rationale: The correct action for a client recovering from a stroke demonstrating slurred speech is to encourage the client to use communication aids, such as writing. This intervention can help the client effectively communicate while working on regaining speech abilities. Consulting the healthcare provider to order speech therapy (choice A) is a valid option, but immediate encouragement of using communication aids is beneficial. Administering aspirin (choice B) without healthcare provider orders is not recommended. Encouraging the client to eat soft foods (choice D) is important for preventing aspiration but doesn't directly address the communication issue.

4. A client with bipolar disorder is prescribed lithium. What should the nurse teach the client about lithium toxicity?

Correct answer: D

Rationale: The correct answer is D. Clients taking lithium should avoid NSAIDs as they can increase lithium levels leading to toxicity. It is essential to monitor lithium levels regularly and maintain hydration to prevent toxicity. Reporting symptoms like nausea, vomiting, or diarrhea is important, but the key teaching point regarding lithium toxicity is to avoid NSAIDs.

5. A client with atrial fibrillation is prescribed warfarin, and their INR is elevated. What is the nurse's priority action?

Correct answer: D

Rationale: An elevated INR in clients taking warfarin increases the risk of bleeding, indicating the dose may be too high. The nurse's priority action is to notify the healthcare provider immediately and hold the next dose of warfarin to prevent bleeding complications. Administering vitamin K is not the first-line intervention for an elevated INR. Monitoring for signs of bleeding is important but not the priority over contacting the healthcare provider. Increasing the warfarin dosage can exacerbate the risk of bleeding and is contraindicated.

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