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 D

Explanation

A. Sodium level: Serum sodium levels can vary and are not a direct measure of fluid retention.

B. Tissue edema: Edema is subjective and can be influenced by other conditions.

C. Urinary output: Many CKD patients have limited or no urine output despite fluid retention.

D. Daily weight: Daily weights are the most reliable non-invasive measure for fluid status.

A. Hamburger on a bun and a banana B. Spaghetti and meat sauce with a breadsticks C. Carrots and spinach D. Cold cuts with bun and fresh pears

Correct Answer is B

Explanation

A. Hamburger on a bun and a banana: Bananas are high in potassium, which must be restricted in CKD. Processed hamburger meat may also be high in sodium and phosphorus.

B. Spaghetti and meat sauce with breadsticks: Pasta and meat sauce are generally low in potassium and phosphorus if made without salt substitutes. Breadsticks are low in potassium.

C. Carrots and spinach: Spinach is high in potassium and phosphorus. Cooked carrots are borderline and must be portion-controlled.

D. Cold cuts with bun and fresh pears: Cold cuts are typically high in sodium and phosphorus. Pears are generally acceptable, but the entire meal is unsuitable due to the cold cuts.

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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 D

Explanation

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Correct Answer is B

Explanation

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