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 A
Explanation
A. Hyperkalemia: In AKI, the kidneys cannot excrete potassium efficiently, leading to elevated potassium levels.
B. Hypernatremia: More common in dehydration but not typically associated with prerenal AKI, where sodium may actually be low due to dilution.
C. Hypophosphatemia: Phosphate tends to increase due to impaired excretion in AKI, not decrease.
D. Hypercalcemia: Calcium levels tend to decrease in AKI due to phosphate retention and reduced vitamin D activation.
Correct Answer is A
Explanation
A. Administering sodium polystyrene sulfonate:
This medication removes potassium through the GI tract and is used to treat hyperkalemia.
B. Initiating an IV potassium infusion:
The client already has hyperkalemia; giving potassium would worsen it.
C. Administering a potassium-sparing diuretic:
These medications retain potassium and would further elevate potassium levels.
D. Encouraging the client to eat bananas:
Bananas are high in potassium and should be avoided in hyperkalemia.
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