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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 B
Explanation
Choice A Reason: Increased pain is not a specific sign of hemorrhage, but it may indicate inflammation, infection, or nerve damage.
Choice B Reason: Continuous swallowing is a sign of hemorrhage, as it indicates that blood is accumulating in the throat or esophagus and stimulating the swallowing reflex.
Choice C Reason: Poor fluid intake is not a sign of hemorrhage, but it may indicate difficulty swallowing, nausea, or dehydration.
Choice D Reason: Drooling is not a sign of hemorrhage, but it may indicate impaired oral control, salivary gland damage, or infection.
Correct Answer is D
Explanation
Choice A Reason: N0 does not indicate presence of regional lymph node involvement, but absence of it. N1 to N3 indicate increasing degrees of regional lymph node involvement.
Choice B Reason: TIS does not indicate that a tumor has been resolved, but that it is in situ, meaning that it is confined to the original site and has not invaded deeper tissues.
Choice C Reason: T4 does not indicate a tumor at its smallest size, but at its largest size. T1 to T4 indicate increasing sizes or extents of the primary tumor.
Choice D Reason: M1 indicates tumor metastasis to a single site, meaning that the cancer has spread to another organ or distant lymph node. M0 indicates no distant metastasis.
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