Question

A nurse is caring for a client who is receiving dialysis.

0630:
Client reports feeling warm, nauseated, and lightheaded; appears restless and slightly confused.
Blood pressure 88/50 mm Hg
Heart rate 110/min
Respiratory rate 24/min
Oxygen saturation 93% on room air

For each potential nursing intervention, click to specify if the intervention is indicated or not indicated (I or NI)

1) Obtain the client's blood glucose level
2) Apply oxygen at 2 L/min via nasal cannula
3) Notify the provider immediately.
4) Place the client in Trendelenburg postion
5) Administer a 0.9% sodium chloride 200 mL IV bolus
6) Perform a 12 lead ECG

Answer 1

Interventions such as checking blood glucose levels, applying oxygen, notifying the provider, administering IV fluids, and performing an ECG are indicated, while placing the client in the Trendelenburg position is not.

Step-by-step explanation:

A client receiving dialysis reports feeling warm, nauseated, and lightheaded; appears restless and slightly confused. The vital signs show a low blood pressure, increased heart rate, respiratory rate, and slightly decreased oxygen saturation, indicating potential complications such as dialysis disequilibrium syndrome, hypotension, or infection.

For the potential nursing interventions:

• Obtain the client's blood glucose level (I) - It is important to check the blood glucose level as hypoglycemia can cause similar symptoms and must be ruled out or addressed.
• Apply oxygen at 2 L/min via nasal cannula (I) - Based on the oxygen saturation level, supplemental oxygen may be beneficial to the patient.
• Notify the provider immediately (I) - These symptoms could indicate a serious condition that requires prompt medical attention.
• Place the client in the Trendelenburg position (NI) - This position is typically utilized for cases of severe hypotension, but could potentially worsen cerebral edema in patients with dialysis disequilibrium syndrome.
• Administer a 0.9% sodium chloride 200 mL IV bolus (I) - This intervention could help to address the hypotension.
• Perform a 12 lead ECG (I) - To assess for any cardiac issues that could be causing or contributing to the symptoms.