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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Telling the partner to call the nurse to push the button is not appropriate. PCA is designed to allow the client to self-administer pain medication based on their own perception of pain. Only the client should press the button to avoid the risk of over-sedation and respiratory depression.
Choice B reason: Encouraging the partner to press the button while the client is asleep can lead to over-medication and serious complications such as respiratory depression.
Choice C reason: Asking the partner why they think more medication is needed when the client is asleep does not address the underlying issue of inappropriate use of the PCA pump.
Choice D reason: The correct answer is d because the client should be the one to decide when more medication is needed. This ensures that the client receives the appropriate amount of pain relief based on their individual needs and prevents the risk of over-sedation.
Correct Answer is C
Explanation
Choice A reason: While early CPR is crucial, the AED should be attached as soon as it is available to analyze the heart rhythm and provide a shock if needed. Delaying the use of the AED can reduce the chances of successful resuscitation.
Choice B reason: In adults, the carotid pulse is typically checked, not the brachial pulse. The brachial pulse is more commonly assessed in infants.
Choice C reason: The correct answer is c because providing chest compressions at a rate of 100-120 compressions per minute is the recommended rate for effective CPR. High-quality chest compressions are essential for maintaining circulation during cardiac arrest.
Choice D reason: The recommended ratio of chest compressions to rescue breaths is 30:2, not 50:2. Performing 50 compressions before providing rescue breaths is not aligned with current CPR guidelines.
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