# A nurse is assessing a patient who has just completed a hemodialysis session. Which assessment finding would be the most concerning and require immediate intervention?

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> subject: Adult Health

## 문제

A nurse is assessing a patient who has just completed a hemodialysis session. Which assessment finding would be the most concerning and require immediate intervention?

## 보기

1. Blood pressure decrease from 160/90 mmHg to 130/80 mmHg with dizziness and palpitations
2. New onset of chest pain with shortness of breath and anxiety **✔ 정답**
3. Mild cramping in the lower extremities
4. Access site bleeding that stops with direct pressure

**정답: 2**

## 해설

Chest pain with shortness of breath and anxiety may indicate air embolism, a life-threatening complication requiring immediate intervention. Other findings like BP decrease, cramping, or controlled bleeding are common post-dialysis effects manageable with standard care.

## 심화 해설

Clinical Reasoning and Prioritization

The most concerning finding requiring immediate intervention is new onset of chest pain with shortness of breath and anxiety. In the context of a patient who has just completed a hemodialysis session, this cluster of symptoms is a classic presentation of a life-threatening emergency, such as an air embolism or acute coronary syndrome, both of which demand a rapid response. The underlying mechanism of the dyspnea and chest pain can be explained by the pathophysiological concept of an imbalance between inspiratory neural drive (IND) and the dynamic response of the respiratory and cardiovascular systems . A sudden disruption, such as air entering the venous system and obstructing pulmonary circulation, creates a catastrophic mismatch where the respiratory center's command for breathing is met with a severely compromised ability of the heart and lungs to respond, leading to the intense sensation of air hunger, chest tightness, and a sense of impending doom .

Analysis of Other Options

While the other options represent common post-dialysis complications, they do not signal an immediate threat to airway, breathing, or circulation in the same way.

-   Option 1: A blood pressure decrease from 160/90 mmHg to 130/80 mmHg with dizziness and palpitations is concerning for intradialytic hypotension and hypovolemia. This is a common complication due to rapid fluid removal. The priority intervention is to place the patient in the Trendelenburg position and administer a fluid bolus, but it does not take precedence over a potential air embolism or acute coronary event.

-   Option 3: Mild cramping in the lower extremities is a frequent and expected complication, often related to electrolyte shifts and fluid removal. It is managed with stretching, massage, or adjusting the dialysate composition but is not immediately life-threatening.

-   Option 4: Access site bleeding that stops with direct pressure indicates a functioning hemostatic response and does not require immediate intervention beyond continued monitoring. The competency to manage vascular access complications is a core skill for hemodialysis nurses, and a bleeding episode that resolves with direct pressure is a standard, non-emergent finding .

NCLEX-RN Practice Application

This question tests your ability to prioritize using the ABC (Airway, Breathing, Circulation) framework and to recognize a cluster of symptoms that points to a high-acuity event. A new onset of chest pain and dyspnea immediately after dialysis should trigger an assessment for air embolism, a rare but critical complication. The nurse must immediately clamp the venous line, place the patient in the left lateral Trendelenburg position to trap air in the right atrium, and administer high-flow oxygen. The assessment of physical fatigue, a common chronic symptom in maintenance hemodialysis patients, is a separate, non-emergent nursing concern that would not be the priority in this acute scenario . The development of a comprehensive emergency response competency for hemodialysis nurses emphasizes the critical importance of rapid recognition and management of such life-threatening complications .

## 임상 시나리오

Post-Hemodialysis Chest Pain ResponseImmediate Action for Air Embolism
New onset of chest pain, dyspnea, and anxiety post-dialysis is a classic triad for air embolism or acute coronary syndrome. This requires immediate intervention.

First action: Clamp the venous line, stop the dialysis machine, and place the patient in the left lateral Trendelenburg position to trap air in the right atrium. Administer 100% oxygen and notify the provider immediately.

CautionDo not confuse this with common intradialytic hypotension. A drop in blood pressure with dizziness is managed with fluids and positioning, but chest pain and dyspnea signal a life-threatening emergency requiring a different, rapid response.

## 핵심 개념

- **Air Embolism** — A life-threatening condition where air enters the venous system, obstructing pulmonary circulation and causing chest pain, dyspnea, and anxiety.
- **Intradialytic Hypotension** — A common complication of hemodialysis caused by rapid fluid removal, leading to a drop in blood pressure, dizziness, and palpitations.

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