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Text 1:
A client has an arteriovenous fistula in place for hemodialysis. What should the nurse do to assess the patency of the fistula?
Irrigate the fistula with 3 mL of normal saline solution.
Flush the fistula with 1 mL of heparin solution once per shift.
Infuse 50 mL of normal saline once per 24 hours.
Palpate for a vibrating sensation at the fistula site.
The Correct Answer is D
Choice A Reason: Irrigating the fistula with 3 mL of normal saline solution is not a correct way to assess the patency of the fistula, as it may cause bleeding, infection, or dislodgement of the fistula.
Choice B Reason: Flushing the fistula with 1 mL of heparin solution once per shift is not a correct way to assess the patency of the fistula, as it may cause clotting, infection, or allergic reaction.
Choice C Reason: Infusing 50 mL of normal saline once per 24 hours is not a correct way to assess the patency of the fistula, as it may cause fluid overload, hypertension, or edema.
Choice D Reason: Palpating for a vibrating sensation at the fistula site is a correct way to assess the patency of the fistula, as it indicates that there is adequate blood flow through the fistula. This sensation is also known as a thrill.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: Loss of erythropoietin will not result in diminished immunologic function, but it may affect the production of some white blood cells and antibodies.
Choice B Reason: Loss of erythropoietin will not result in hypertension, but it may cause hypotension due to reduced blood volume and viscosity.
Choice C Reason: Loss of erythropoietin will not result in elevated lipid levels in the bloodstream, but it may be associated with dyslipidemia due to other factors such as malnutrition, inflammation, or medication use.
Choice D Reason: Loss of erythropoietin will result in anemia, as erythropoietin is a hormone that stimulates the bone marrow to produce red blood cells.
Correct Answer is A
Explanation
Choice A Reason: Contacting the health care provider is the first nursing action that the nurse should perform, as it indicates that the client may have compartment syndrome, which is a medical emergency that requires immediate intervention to prevent tissue necrosis and nerve damage.
Choice B Reason: Administering PRN pain medication is not the first nursing action that the nurse should perform, as it may not relieve the pain and may mask the symptoms of compartment syndrome.
Choice C Reason: Documenting the findings is not the first nursing action that the nurse should perform, as it may delay the treatment and worsen the outcome of compartment syndrome.
Choice D Reason: Elevating the extremity is not the first nursing action that the nurse should perform, as it may decrease blood flow and increase tissue ischemia in compartment syndrome.
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