A nurse is assessing a client's arteriovenous fistula prior to hemodialysis, but does not hear a bruit or feel a thrill. Pulses distal to the fistula are not palpable, and the capillary refill is slow. Which of the following actions is the nurse's priority?
Proceed with hemodialysis.
Notify the provider immediately.
Raise the arm above the level of the patient's heart.
Apply warm packs to the fistula site and reassess.
The Correct Answer is B
A. This is incorrect and potentially dangerous. A non-functioning fistula will not provide adequate blood flow for dialysis and can lead to complications.
B. This is the correct action. The nurse should immediately inform the healthcare provider about the compromised fistula. The provider can order further diagnostic tests or interventions as needed.
C. This might improve blood flow temporarily, but it is not a definitive solution and does not address the underlying issue.
D. While warm packs can sometimes improve circulation, it is unlikely to resolve the serious issues found in this case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Frequent ambulation could exacerbate the edema and is not a priority in the acute management of this condition.
B. Obtaining weight weekly is an appropriate intervention to monitor for changes in fluid status and guide treatment decisions.
C. A low-protein diet is not a standard treatment for PSGN.
D. Encouraging increased fluid intake is not recommended due to the client's oliguria and risk of fluid overload
Correct Answer is D
Explanation
A. Hyperkalemia and hypernatremia are generally not associated with the diuretic phase of AKI. In the diuretic phase, the primary issue is excessive loss of electrolytes and fluid, rather than their accumulation.
B. Hypokalemia can occur during the diuretic phase because diuretics increase the excretion of potassium along with water. Hypernatremia is not typical of the diuretic phase. Instead, sodium levels might decrease or remain normal due to the loss of fluid and electrolytes.
C. Hyperkalemia is unlikely during the diuretic phase as diuretics often lead to increased potassium loss. Hyponatremia is a more likely outcome during the diuretic phase due to the loss of sodium and fluid through increased urine output.
D. During the diuretic phase of AKI, there is significant loss of electrolytes, including potassium and sodium. Diuretics increase urine output, leading to the loss of potassium and sodium, which can occur as a result of excessive fluid and electrolyte loss.
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