A nurse is caring for a client post hemodialysis. The nurse assesses bleeding at the AV fistula site, the nurse should prioritize which of the following actions?
Obtain a complete blood count (CBC)
Start IV fluids
Apply direct pressure
Administer pain medication
The Correct Answer is C
A. Obtain a complete blood count (CBC): This is not the immediate action in an active bleeding scenario.
B. Start IV fluids: This may be needed later if significant blood loss occurs, but not the first response.
C. Apply direct pressure: Bleeding from a fistula requires immediate direct pressure to prevent blood loss and preserve vascular access.
D. Administer pain medication: Pain management is important but not the priority in acute bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Orange juice: Does not affect cyclosporine metabolism.
B. Bananas: No known interaction with cyclosporine.
C. Grapefruit juice: Inhibits CYP3A4 enzyme in the liver, which increases cyclosporine levels, leading to toxicity.
D. Smoked salmon: May contain sodium but does not interact with cyclosporine metabolism.
Correct Answer is B
Explanation
A. Oxygen saturation 93%:
While this is slightly below normal, it is not a definitive or specific indicator of fluid overload.
B. Distended neck veins:
Jugular vein distention is a classic sign of fluid overload and increased central venous pressure.
C. The client has gained 1 pound since yesterday:
A 1-pound weight gain could be due to fluid retention, but it's not significant enough on its own to confirm fluid overload.
D. Return of skin to previous position when the client's shin is palpated:
This indicates normal skin turgor and does not suggest fluid overload; instead, it rules out dehydration.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
