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 D
Explanation
A. Hematuria with abdominal bruising: Hematuria refers to blood in the urine but is not directly associated with the bruising characteristic of Grey Turner sign.
B. Bladder spasms on palpation of the abdomen: This does not describe Grey Turner sign, which is related to bleeding.
C. Distended bladder with painful urination: Grey Turner sign is not linked to bladder distension or urination issues.
D. Retroperitoneal bleeding and bruising over the flank: Grey Turner sign indicates retroperitoneal bleeding and is observed as bruising on the flanks, often a result of trauma or pancreatitis.
Correct Answer is B
Explanation
A. Specific gravity: Specific gravity measures urine concentration but does not directly assess renal function.
B. Creatinine: Serum creatinine levels provide the most accurate measure of renal function as they reflect the kidney’s ability to filter waste.
C. Phosphates: Phosphate levels are affected by kidney function but are not the most direct measure.
D. BUN: Blood Urea Nitrogen (BUN) can be affected by other factors like hydration and protein intake, making it less reliable than creatinine.
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