A nurse is caring for a patient with an atrioventricular (AV) fistula in the forearm and assesses that a trill is absent when palpating the venous side of the fistula. What action should the nurse implement?
Inject the ordered amount of heparin into the fistula.
Apply warm compresses and lower the arm below the heart level.
Send the patient to dialysis for remedy.
Report to the charge nurse that the fistula is occluded.
The Correct Answer is D
A. Inject the ordered amount of heparin into the fistula: Heparin is not used to treat occlusion in a fistula without specific orders or a proper diagnostic workup.
B. Apply warm compresses and lower the arm below the heart level: These interventions are not effective for resolving an absent trill in an AV fistula.
C. Send the patient to dialysis for remedy: The absence of a trill requires immediate assessment before considering dialysis treatment.
D. Report to the charge nurse that the fistula is occluded: An absent trill may indicate occlusion or thrombosis of the AV fistula, which requires urgent evaluation and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E","F"]
Explanation
A. Topical estrogen: Estrogen therapy is used for recurrent UTIs in postmenopausal women due to atrophic changes but is not directly for UTI treatment.
B. Urinary tract antiseptics: These are used to prevent and treat UTIs by exerting a local antibacterial effect.
C. Diuretics: Diuretics promote urine production but do not treat infections.
D. Antispasmodic agents: These relieve bladder spasms associated with UTIs.
E. Antibiotics: Antibiotics are the primary treatment for UTIs.
F. Analgesics: Analgesics, such as phenazopyridine, are used to manage pain caused by UTIs.
Correct Answer is ["C","D"]
Explanation
A. Trace glucose: Trace glucose in the urine is not typically associated with infections; it may indicate diabetes or impaired glucose tolerance.
B. Straw color: Straw-colored urine is normal and does not indicate infection.
C. Foul odor: A foul odor in urine can be indicative of infection due to bacterial activity.
D. pH of 8.2: Alkaline urine (pH > 8.0) may indicate infection because some bacteria produce urease, which increases urine pH.
E. Specific gravity of 1.014: This is within the normal range and does not indicate infection.
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