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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Omeprazole: Not directly nephrotoxic, but long-term use has been associated with interstitial nephritis, although rarely.

B. Ondansetron: Generally safe in renal disease and not known to cause nephrotoxicity.

C. Vancomycin: Known nephrotoxic agent, especially with high trough levels or when used with other nephrotoxins; requires dose adjustment in CKD.

D. Diphenhydramine: Not nephrotoxic; primarily affects the CNS and anticholinergic systems.

A. Client with partial and deep partial thickness burns on the face and neck with high-pitched respiratory sounds B. Client with facial burns and expectorating sooty secretions in no distress C. Client with dry, black skin on both hands and a history of diabetes mellitus D. Client with moist blisters over the back and who reports pain as 10

Correct Answer is A

Explanation

A. Client with partial and deep partial thickness burns on the face and neck with high-pitched respiratory sounds: High-pitched respiratory sounds (stridor) suggest impending airway obstruction, which is life-threatening and requires immediate intervention.

B. Client with facial burns and expectorating sooty secretions in no distress: At risk for inhalation injury but not in immediate respiratory distress.

C. Client with dry, black skin on both hands and a history of diabetes mellitus: Eschar and possible full-thickness burns are serious but not immediately life-threatening compared to airway compromise.

D. Client with moist blisters over the back and who reports pain as 10: Pain is expected and manageable; airway takes priority.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is A

Explanation

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