Which finding for a client with an arteriovenous fistula (AV Fistula) should the practical nurse (PN) report to the healthcare provider?

Descriptions of numbness and tingling in fingers distal to the AVF.

A loud and consistent bruit is auscultated at the AVF site.

Bruising at the AVF site is purple and green in color.

Radial pulse distal to AVF is absent and ulnar pulse is present.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A: Descriptions of numbness and tingling in fingers distal to the AVF.

Choice A rationale:

Descriptions of numbness and tingling in fingers distal to the arteriovenous fistula (AVF) suggest possible nerve compression or impaired blood flow, which are concerning findings. These symptoms could indicate reduced perfusion to the distal extremities and require immediate attention to prevent further complications.

Choice B rationale:

A loud and consistent bruit auscultated at the AVF site is an expected finding and indicates adequate blood flow through the fistula. A bruit is the sound of turbulent blood flow and is commonly heard over functional AV fistulas.

Choice C rationale:

Bruising at the AVF site is a common occurrence after the creation of the fistula. It is expected due to the surgical intervention and the manipulation of blood vessels. As long as the bruising is not severe or accompanied by other concerning symptoms, it does not need immediate reporting.

Choice D rationale:

The absence of the radial pulse distal to the AVF and the presence of the ulnar pulse are normal findings in a functioning AV fistula. The AV fistula diverts blood flow away from the radial artery, leading to a diminished pulse. This is not a cause for concern as long as the ulnar pulse is present, indicating adequate perfusion to the hand.

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Correct Answer is C

Explanation

The correct answer is choice C. Red welts widespread over the chest.

Choice A rationale:

Ulceration on the corner of the upper lip does not indicate a need for loratadine administration. Loratadine is an antihistamine commonly used to relieve symptoms of allergies such as sneezing, runny nose, and itchy or watery eyes. Ulceration on the lip is not associated with an allergic reaction.

Choice B rationale:

Ecchymosis and petechiae on the legs are not related to the need for loratadine. These findings suggest potential bleeding or clotting disorders, and loratadine does not address such issues.

Choice C rationale:

Red welts widespread over the chest are indicative of hives (urticaria), which are often caused by allergic reactions. Loratadine can help alleviate the symptoms of hives by blocking histamine release, making it an appropriate choice for this condition.

Choice D rationale:

Red papules and pustules on the face are unlikely to be treated with loratadine. These skin manifestations may be related to various dermatological conditions, but not necessarily allergic reactions that loratadine is primarily used to manage.

A. Have the client sit down in the hall. B. Assist the client back to the room. C. Administer sublingual nitroglycerin. D. Obtain a 12-lead electrocardiogram.

Correct Answer is A

Explanation

The correct answer is choice A: Have the client sit down in the hall.

Choice A rationale: The PN should first have the client sit down to help alleviate the client's chest tightness and shortness of breath. Sitting down allows for better lung expansion and reduces the risk of falling due to dizziness or lightheadedness. This is the most appropriate initial action in response to the client's complaint.

Choice B rationale: While assisting the client back to their room is important, the PN should first ensure that the client is sitting down to help manage their symptoms. After the client is seated and more stable, the PN can then assist them back to their room for further assessment and intervention.

Choice C rationale: Administering sublingual nitroglycerin may be appropriate if the client is experiencing cardiac-related chest pain. However, the PN should first have the client sit down and gather more information about their symptoms before administering any medications.

Choice D rationale: Obtaining a 12-lead electrocardiogram can help assess the client's cardiac status, but it is not the first action that the PN should take in this situation. Ensuring the client's safety and managing their symptoms are immediate priorities. The PN can consider obtaining an electrocardiogram after addressing the client's immediate needs and assessing their condition further.

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Which finding for a client with an arteriovenous fistula (AV Fistula) should the practical nurse (PN) report to the healthcare provider?

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Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is caring for a client who has a prescription for loratadine by mouth daily as needed. Which sign indicates to the PN that there is a need to administer the medication?

Correct Answer is C

Explanation

While ambulating in the hallway following an appendectomy yesterday, a client complains of chest tightness and shortness of breath. Which action should the practical nurse (PN) implement first?

Correct Answer is A

Explanation

Which finding for a client with an arteriovenous fistula (AV Fistula) should the practical nurse (PN) report to the healthcare provider?

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