A nurse is monitoring a client following a hemodialysis treatment through an arteriovenous (AV) fistula. Which of the following findings should the nurse report to the provider?

Blood pressure 134/82 mm Hg

Headache, restlessness

Palpable thrill at the AV fistula access site

Heart rate 65 bpm

Answer and Explanation

The Correct Answer is B

Choice A reason: A blood pressure of 134/82 mm Hg is within the normal range and typically does not require immediate intervention. It is important to monitor blood pressure trends, but this value alone is not concerning.

Choice B reason: The correct answer is b because headache and restlessness can be signs of dialysis-related complications such as disequilibrium syndrome or fluid and electrolyte imbalances. These symptoms should be reported to the provider for further evaluation and management.

Choice C reason: A palpable thrill at the AV fistula access site indicates that the fistula is functioning properly. This is an expected finding and does not require intervention.

Choice D reason: A heart rate of 65 bpm is within the normal range for most adults and does not typically require immediate intervention unless associated with other symptoms or abnormalities.

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Correct Answer is C

Explanation

Choice A reason: Keeping a tongue stud in during surgery poses a risk of aspiration and is not allowed. All body piercings should be removed before surgery to ensure safety.

Choice B reason: Consuming clear liquids up to the time of surgery is not allowed. Clients are typically required to fast for a certain period before surgery to prevent aspiration during anesthesia.

Choice C reason: The correct answer is c because allowing the client to keep her hearing aids in helps facilitate communication until the last possible moment before surgery. This helps reduce anxiety and ensures the client understands preoperative instructions.

Choice D reason: Taking morning vitamins before surgery is not recommended, as clients are usually required to fast. Medications, including vitamins, should be reviewed and managed by the healthcare provider.

A. "I will not eat fried foods." B. "I will abstain from sexual intercourse." C. "I will refrain from international travel." D. "I will not order a salad in a restaurant."

Correct Answer is B

Explanation

Choice A reason: While a healthy diet is important, avoiding fried foods alone is not sufficient for managing hepatitis A. This statement does not fully address the necessary precautions to prevent transmission.

Choice B reason: The correct answer is b because abstaining from sexual intercourse is essential to prevent the spread of hepatitis A. The virus can be transmitted through close personal contact, including sexual activity.

Choice C reason: Refraining from international travel may be advisable in some cases, but it is not a specific requirement for managing hepatitis A. This statement does not directly address transmission prevention.

Choice D reason: Avoiding salads in restaurants can help reduce the risk of foodborne transmission of hepatitis A, but it is not as comprehensive as abstaining from sexual intercourse, which directly prevents person-to-person transmission.

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A nurse is monitoring a client following a hemodialysis treatment through an arteriovenous (AV) fistula. Which of the following findings should the nurse report to the provider?

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Naxlex Comprehensive Predictor Exams

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