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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: Compressing the nares is not the first action that the nurse should take, as it may increase intracranial pressure and worsen the head injury.
Choice B Reason: Administering decongestant for postnasal drip is not the first action that the nurse should take, as it may mask the signs of cerebrospinal fluid (CSF) leakage and delay diagnosis and treatment.
Choice C Reason: Tilting the head back is not the first action that the nurse should take, as it may cause aspiration of CSF or blood and increase the risk of infection.
Choice D Reason: Collecting the drainage is the first action that the nurse should take, as it helps to identify if the drainage is CSF or nasal secretions, and to monitor the amount and characteristics of the drainage.
Correct Answer is D
Explanation
Choice A Reason: Hypertension is not a common finding in diabetes insipidus, but it may indicate increased intracranial pressure or other complications.
Choice B Reason: Fluid retention is not a common finding in diabetes insipidus, but it may indicate syndrome of inappropriate antidiuretic hormone secretion (SIADH) or heart failure.
Choice C Reason: Elevated blood glucose is not a common finding in diabetes insipidus, but it may indicate diabetes mellitus or hyperglycemia.
Choice D Reason: Increased urine output is a common finding in diabetes insipidus, as the lack of antidiuretic hormone (ADH) causes the kidneys to excrete large amounts of diluted urine.
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