The nurse is caring for a client with End Stage Renal Disease has a mature Arteriovenous Fistula. Which of the following interventions would the nurse include in the client's plan of care?
Select All that Apply

Avoid drawing blood from the affected extremity

Auscultate the fistula for the sound of a bruit

Palpate the site to identify the presence of a thrill

Irrigate the fistula with saline to maintain patency

Keep the fistula clamped until ready to perform dialysis

Answer and Explanation

Correct Answer : A,B,C

A. Avoid drawing blood from the affected extremity: Blood draws, IVs, and BP measurements should never be done on the fistula arm to prevent damage and thrombosis.

B. Auscultate the fistula for the sound of a bruit: A bruit (whooshing sound) confirms blood flow through the fistula, indicating patency.

C. Palpate the site to identify the presence of a thrill: A thrill (vibration) should be felt over the fistula. Absence may indicate clotting or failure.

D. Irrigate the fistula with saline to maintain patency: A fistula is never irrigated. Only dialysis staff should access it.

E. Keep the fistula clamped until ready to perform dialysis: AV fistulas are not clamped. Clamping could obstruct blood flow.

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Correct Answer is B

Explanation

A. Blood-tinged: Pancreatic cancer does not typically cause rectal bleeding.

B. Clay: Blockage of the bile duct leads to pale (clay-colored) stools due to lack of bilirubin.

C. Brown: Normal stools are brown due to bilirubin metabolism.

D. Chalky: Chalky is not a typical term used for stool description in pancreatic cancer.

A. Viral hepatitis B. High fiber diet C. Chronic pancreatitis D. Regular exercise

Correct Answer is C

Explanation

A. Viral hepatitis: Hepatitis B and C are risk factors for liver cancer, not pancreatic cancer. There is no strong link between hepatitis and pancreatic cancer.

B. High-fiber diet: A high-fiber diet is protective against colorectal cancer, not a risk factor for pancreatic cancer.

C. Chronic pancreatitis: Chronic inflammation of the pancreas increases the risk of pancreatic cancer by causing long-term cellular damage and mutations.

D. Regular exercise: Exercise reduces the risk of many cancers, including pancreatic cancer. Sedentary lifestyles and obesity increase the risk.

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The nurse is caring for a client with End Stage Renal Disease has a mature Arteriovenous Fistula. Which of the following interventions would the nurse include in the client's plan of care? Select All that Apply

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The nurse is caring for a client with End Stage Renal Disease has a mature Arteriovenous Fistula. Which of the following interventions would the nurse include in the client's plan of care?
Select All that Apply