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 A
Explanation
A. This method is the most reliable for measuring fluid retention. Weight changes are a direct indicator of fluid balance because fluid retention or loss affects body weight. By comparing the client's current weight to their post-dialysis weight, you can determine the amount of fluid they have retained.
B. Creatinine and blood urea nitrogen (BUN) levels are indicators of kidney function rather than fluid volume status. Elevated levels can indicate worsening kidney function but do not directly measure fluid retention or overload.
C. While assessing skin turgor and peripheral edema can provide some clues about fluid overload, these signs are less precise and subjective compared to weight measurements. Skin turgor changes and edema can be influenced by various factors, including skin elasticity and other conditions, making them less reliable for accurately measuring fluid volume changes since the last dialysis.
D. Crackles in lung sounds can indicate pulmonary congestion due to fluid overload, but this method is not as precise for quantifying the amount of fluid retained. Crackles suggest fluid accumulation in the lungs, which is a sign of more severe fluid overload but does not provide a specific measurement of fluid volume compared to changes in body weight.
Correct Answer is D
Explanation
A. A prostate examination is typically performed for issues related to the prostate, such as benign prostatic hyperplasia or prostate cancer. It is not relevant to diagnosing or managing acute glomerulonephritis, which is related to kidney inflammation rather than prostate issues.
B. A blood glucose check is used to diagnose and manage diabetes. While diabetes can contribute to chronic kidney disease, it is not the primary test for diagnosing acute glomerulonephritis or identifying its most common cause.
C. Genetic testing is useful for diagnosing inherited conditions or genetic predispositions to diseases. However, acute glomerulonephritis is typically caused by an infection or an autoimmune reaction, and genetic testing is not the primary diagnostic tool for this condition.
D. Antistreptolysin-O (ASO) titers are tests used to detect antibodies produced in response to a streptococcal infection. Elevated ASO titers indicate a recent streptococcal infection, which is the most common cause of post-infectious acute glomerulonephritis.
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