# A client receiving hemodialysis develops severe muscle cramping and hypotension during the treatment session. Which nursing intervention should the nurse implement first?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=541419  
> language: ko  
> subject: Adult Health

## 문제

A client receiving hemodialysis develops severe muscle cramping and hypotension during the treatment session. Which nursing intervention should the nurse implement first?

## 보기

1. Administer prescribed antihypertensive medication
2. Increase the ultrafiltration rate to remove more fluid
3. Decrease the ultrafiltration rate and administer normal saline **✔ 정답**
4. Stop the dialysis treatment immediately and notify the physician

**정답: 3**

## 해설

Severe muscle cramping and hypotension during hemodialysis are often due to rapid fluid removal causing hypovolemia. The priority intervention is to decrease the ultrafiltration rate and administer normal saline to restore fluid volume and stabilize blood pressure.

## 심화 해설

Understanding the Clinical Scenario

During a hemodialysis session, a client develops severe muscle cramping and hypotension. This is a classic presentation of intravascular volume depletion occurring too rapidly for the body's compensatory mechanisms to adapt. The immediate priority is to address the underlying cause—excessive or overly rapid fluid removal—while stabilizing the client's hemodynamic status.

Analysis of the Correct Answer (Option 3)

Decrease the ultrafiltration rate and administer normal saline is the most appropriate first intervention. This action directly targets the pathophysiology of the problem. Intradialytic hypotension (IDH) and associated cramping are frequently driven by a decline in relative blood volume (RBV) that outpaces plasma refilling from the interstitial space [4]. By slowing the ultrafiltration rate, you immediately reduce the rate of intravascular volume loss. The administration of a 0.9% normal saline bolus provides rapid intravascular volume expansion, increasing blood pressure and improving muscle perfusion, which alleviates cramping. Continuous RBV monitoring research confirms that real-time trajectories can indicate IDH risk, and interventions that restore circulating volume are critical to prevent end-organ injury [4].

Why the Other Options Are Incorrect

- Option 1: Administer prescribed antihypertensive medication. This is contraindicated. The client is already hypotensive; administering an antihypertensive would further lower blood pressure, potentially causing cardiovascular collapse and worsening tissue hypoperfusion.

- Option 2: Increase the ultrafiltration rate to remove more fluid. This would exacerbate the problem. Increasing fluid removal accelerates the drop in RBV, intensifying hypotension and the neuromuscular irritability that leads to cramping. The pathophysiology of cramping, while complex, is linked to reduced muscle perfusion, and an intervention that further reduces circulating volume is harmful .

- Option 4: Stop the dialysis treatment immediately and notify the physician. While notifying the physician is an important step, stopping treatment entirely is not the first intervention for a hypotensive cramping episode. The immediate nursing action is to manage the acute complication with a volume challenge and reduced fluid removal. If the client does not respond to these measures, then stopping treatment and further escalation would be warranted. The priority is to intervene to stabilize the client without unnecessarily cutting the treatment short.

Underlying Pathophysiology and Nursing Implications

The development of cramps and hypotension is a multifactorial process. The primary driver during treatment is often a mismatch between the ultrafiltration rate and the plasma refill rate, leading to a critical reduction in central blood volume. This triggers compensatory vasoconstriction, but in vulnerable patients, this compensation fails, leading to hypotension and reduced blood flow to skeletal muscles, which manifests as painful cramping [4]. Research into preventive strategies, such as nurse-led intradialytic stretching exercises, aims to reduce this cramp burden by potentially improving local muscle circulation and tolerance to volume shifts, highlighting the importance of proactive nursing measures . Furthermore, in rare cases, a high-flow arteriovenous fistula can cause a vascular steal phenomenon, reducing distal limb perfusion and contributing to severe cramps, a mechanism that is reversed by fistula ligation, which restores regional blood flow . Experimental therapies like angiotensin II infusion are being studied for their potential to maintain systemic vascular resistance and muscle perfusion during fluid removal, directly counteracting the ischemic component of cramping . Understanding these mechanisms reinforces why the nurse's immediate response must focus on restoring effective circulating volume by decreasing fluid removal and administering a fluid bolus.References (research sources)

- [4]Continuous monitoring of relative blood volume allows real-time assessment of intradialytic hypotension risk.Research articleAniort J, Bachelet T, Seris P, Dolley-Hitze T, Bouiller M, Beji C, Batel V, Pereira B, Attaf D, Kopperschmidt P, Heng AE, Canaud B. (2026) · DOI: 10.1093/ckj/sfag052

## 임상 시나리오

Managing Intradialytic Hypotension & CrampsImmediate Nursing Intervention
The priority is to correct intravascular volume depletion by simultaneously reducing fluid removal and expanding volume. First, decrease the ultrafiltration rate to slow the loss of vascular volume. Then, administer a 0.9% normal saline bolus (typically 100-200 mL) to rapidly restore circulating volume and perfusion.

Place the patient in the Trendelenburg position if hypotension is severe, and administer supplemental oxygen. Monitor relative blood volume (RBV) trends if available, as a steep decline often precedes symptomatic hypotension.

CautionNever administer antihypertensive medications to a hypotensive patient. Do not increase the ultrafiltration rate, as this will worsen hypovolemia and may lead to cardiovascular collapse. Stopping dialysis is reserved for non-responders to initial volume resuscitation.

## 핵심 개념

- **Ultrafiltration** — The process of removing fluid from the blood during hemodialysis by applying a pressure gradient across the dialyzer membrane.
- **Intradialytic Hypotension (IDH)** — A drop in blood pressure during dialysis, commonly defined as a decrease in systolic BP ≥20 mmHg or a decrease in MAP ≥10 mmHg, often caused by rapid fluid removal.
- **Relative Blood Volume (RBV)** — A real-time monitoring parameter reflecting changes in intravascular volume during dialysis, used to predict and manage hypotension.
- **Plasma Refilling Rate** — The rate at which fluid shifts from the interstitial space into the vascular compartment to compensate for volume removed during ultrafiltration.
- **Normal Saline Bolus** — An isotonic 0.9% sodium chloride solution administered intravenously to rapidly expand intravascular volume.

## 같은 주제 문제

- [A nurse is assessing a patient who has just completed a hemodialysis session. Which assess…](https://mymerci.kr/pages/nclex_q.php?qn_id=541416)
- [A nurse is caring for a client receiving hemodialysis. Which assessment finding would be t…](https://mymerci.kr/pages/nclex_q.php?qn_id=541417)
- [A nurse is caring for a client receiving hemodialysis. Which assessment finding would be t…](https://mymerci.kr/pages/nclex_q.php?qn_id=541418)
- [A nurse is caring for a client receiving hemodialysis who suddenly develops chest pain, dy…](https://mymerci.kr/pages/nclex_q.php?qn_id=541420)
- [A nurse is caring for a client receiving hemodialysis when the client suddenly develops ch…](https://mymerci.kr/pages/nclex_q.php?qn_id=541421)
- [A nurse is caring for a client receiving hemodialysis when the client suddenly develops ch…](https://mymerci.kr/pages/nclex_q.php?qn_id=541422)
- [A nurse is caring for a client receiving hemodialysis when the client suddenly develops ch…](https://mymerci.kr/pages/nclex_q.php?qn_id=541423)
- [A nurse is caring for a client receiving hemodialysis when the client suddenly develops ch…](https://mymerci.kr/pages/nclex_q.php?qn_id=541424)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._