A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency?

Cold and numb sensation distal to the fistula site

A raised red rash around the fistula site

Pain in the right arm proximal to the fistula site

Foul-smelling drainage from the fistula site

Answer and Explanation

The Correct Answer is A

Choice A: Cold and numb sensation distal to the fistula site is a possible indication of venous insufficiency. Venous insufficiency is a condition in which the veins have difficulty returning blood from the limbs to the heart, resulting in blood pooling and reduced perfusion. A new arteriovenous fistula can cause increased blood ﬂow through the artery and decreased blood ﬂow through the vein, leading to venous insufficiency. This can manifest as coldness, numbness, tingling, or cyanosis in the fingers or hand below the fistula site.

Choice B: A raised red rash around the fistula site is not a possible indication of venous insufficiency. A raised red rash around the fistula site can indicate an allergic reaction, an infection, or an inﬂammation of the skin or subcutaneous tissue. The nurse should assess the rash for size, shape, color, texture, temperature, and drainage, and report any signs of infection or inﬂammation, such as fever, pus, or swelling.

Choice C: Pain in the right arm proximal to the fistula site is not a possible indication of venous insufficiency. Pain in the right arm proximal to the fistula site can indicate arterial insufficiency, which is a condition in which the arteries have difficulty delivering oxygen-rich blood to the tissues, resulting in ischemia and necrosis. Arterial insufficiency can be caused by atherosclerosis, thrombosis, embolism, or vasospasm. The nurse should assess the pain for location, intensity, duration, frequency, and quality, and report any signs of ischemia or necrosis, such as pallor, coolness, weak pulses, or ulceration.

Choice D: Foul-smelling drainage from the fistula site is not a possible indication of venous insufficiency. Foul-smelling drainage from the fistula site can indicate an infection of the fistula or surrounding tissue. The nurse should assess the drainage for color, odor, amount, and consistency, and report any signs of infection or sepsis, such as fever, chills, malaise, or hypotension.

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Correct Answer is B

Explanation

Choice A Reason: This is incorrect because the results are not within the expected reference range. The client's BUN, creatinine, and hematocrit are elevated, indicating dehydration or reduced renal perfusion.

Choice B Reason: This is correct because evaluating urine for amount and for specific gravity can help assess the client's hydration status and renal function. These actions can help assess the client's hydration status and renal function, which may be aﬀected by nausea and vomiting. The client's BUN, creatinine, and hematocrit are elevated, indicating dehydration or reduced renal perfusion. The normal ranges for BUN are 7 to 20 mg/dL, for creatinine are

0.6 to 1.2 mg/dL, and for hematocrit are 38% to 50% for males. The nurse should monitor the urine output and specific gravity, which reﬂect the concentration and volume of urine. The normal range for urine output is 30 to 60 mL/hour, and for specific gravity is 1.005 to 1.030.

Choice C Reason: This is incorrect because collecting a urine specimen for culture and sensitivity is not indicated for this client. This action is used to diagnose urinary tract infections, which are not suggested by the client's symptoms or results.

Choice D Reason: This is incorrect because decreasing the IV ﬂuid infusion rate and limiting oral ﬂuid intake can worsen the client's dehydration and renal perfusion. The nurse should maintain adequate ﬂuid intake and balance to prevent further complications.

A. Pulse and blood pressure findings B. Scheduled treatments and client illness C. A self-report pain rating scale D. Behavioral indicators and aﬀect

Correct Answer is C

Explanation

Choice A Reason: This is incorrect. Pulse and blood pressure findings are not reliable indicators of pain, as they can be inﬂuenced by many other factors, such as anxiety, medication, or underlying conditions. They are also not sensitive enough to detect changes in pain intensity or relief.

Choice B Reason: This is incorrect. Scheduled treatments and client illness are not relevant parameters for assessing pain, as they do not reﬂect the current pain experience of the client. They may provide some clues about the possible causes or sources of pain, but they do not measure the pain itself.

Choice C Reason: This is correct. A self-report pain rating scale is the most valid and reliable parameter for assessing pain, as it reﬂects the subjective perception of the client. The nurse should use a simple and appropriate scale, such as a numeric or visual analog scale, and ask the client to point to the number or picture that best represents their pain level.

Choice D Reason: This is incorrect. Behavioral indicators and aﬀect are useful parameters for assessing pain, especially when the client has difficulty communicating verbally, but they are not the first choice. They are more subjective and variable than self-report, and they may be inﬂuenced by cultural or personal factors. They should be used in conjunction with self-report, not instead of it.

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A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency?

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