Hemodialysis

A nurse is caring for a client with chronic kidney disease stage 5 who is on hemodialysis. Which assessment finding would require the nurse to take immediate action?

1 Blood pressure of 90/60 mmHg with mild dizziness
2 Muscle cramping in the lower extremities
3 Air bubbles visible in the arterial line of the dialysis circuit ✓ 정답
4 Nausea and headache during the final hour of treatment

해설

Air bubbles in the arterial line indicate a potential air embolism, a life-threatening emergency requiring immediate action. Other findings are common complications but do not pose an immediate life risk.

같은 주제 다음 문제A nurse is caring for a client receiving hemodialysis. During the treatment, the client su…이 문제가 수록된 문제집[개념+기출] 엔클렉스(NCLEX), 이거 하나면 됩니다69,000원

Analysis of the Correct Answer

The finding that requires immediate action is air bubbles visible in the arterial line of the dialysis circuit. In the context of hemodialysis, the presence of air in the extracorporeal circuit represents a critical and potentially life-threatening emergency due to the risk of air embolism. Modern dialysis machines are equipped with air detectors and safety clamps specifically designed to prevent this complication; however, if air is visualized, it indicates a breach in the system's integrity or a failure of a safety mechanism ^[1]. The immediate nursing action is to stop the blood pump and clamp the venous line to prevent air from entering the patient's systemic circulation. The provided evidence underscores that most hemodialysis emergencies are attributable to human error, and meticulous adherence to safety protocols—including the management of the extracorporeal circuit—is paramount to preventing life-threatening events ^[1].

Analysis of Incorrect Options

Option 1: Blood pressure of 90/60 mmHg with mild dizziness
A blood pressure of 90/60 mmHg accompanied by mild dizziness is a common finding during dialysis, often indicative of intradialytic hypotension. While this requires prompt nursing assessment and intervention—such as placing the patient in the Trendelenburg position, reducing the ultrafiltration rate, or administering a fluid bolus—it is generally a manageable complication, not an immediate life-threatening emergency like an air embolism. The complexity of dialysis treatment and high patient comorbidity make such fluctuations expected, and staff are extensively trained to handle them ^[1].

Option 2: Muscle cramping in the lower extremities
Muscle cramping is a frequent and uncomfortable complication of dialysis, often related to rapid fluid and electrolyte shifts, particularly a reduction in plasma osmolality. While distressing for the patient, it does not pose an immediate threat to life. Management typically involves reducing the ultrafiltration rate or administering hypertonic saline. It does not represent a system failure or a risk of catastrophic injury, unlike a breach in the closed dialysis circuit ^[1].

Option 4: Nausea and headache during the final hour of treatment
Nausea and headache are classic symptoms of dialysis disequilibrium syndrome, which is thought to result from a rapid shift in plasma osmolality causing cerebral edema. This syndrome is most common during initial treatments but can occur in any session. While it requires symptomatic management and potentially a reduction in treatment efficiency for future sessions, it is a known and generally non-fatal complication. It does not demand the same instantaneous, life-saving intervention as the detection of air in the circuit, which can lead to immediate cardiovascular collapse ^[1].

References (research sources)

[1]
Diagnosis, Treatment, and Prevention of Hemodialysis Emergencies.Research articleSaha M, Allon M. (2017) · DOI: 10.2215/cjn.05260516

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A nurse is caring for a client with chronic kidney disease stage 5 who is on hemodialysis. Which assessment finding would require the nurse to take immediate action?

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