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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choiceD. Contact information for a women’s shelter.
Choice A rationale:
While providing a safety plan is important, it may not be the most immediate or practical resource for a client in an abusive situation. A safety plan is a detailed strategy for leaving an abusive relationship safely, but it requires time and preparation, which may not be feasible in an urgent situation.
Choice B rationale:
Paperwork for a restraining order is a legal step that can help protect the client, but it may not provide immediate safety. The process of obtaining a restraining order can take time, and the client may need immediate shelter and support.
Choice C rationale:
Documenting the report of abuse in the visit summary is important for medical and legal records, but it does not directly provide the client with immediate resources or safety. This documentation can be useful for future legal actions but does not address the client’s immediate need for safety and support.
Choice D rationale:
Providing contact information for a women’s shelter is the most appropriate response because it offers immediate safety and support. Women’s shelters provide a safe haven, counseling, legal support, and other resources necessary for individuals experiencing domestic violence.This option prioritizes the client’s immediate safety and well-being.
Correct Answer is C
Explanation
The correct answer is choice C - Paresthesia, paralysis, pedal pulses, pallor, and pain.
Choice A rationale:
Clear lung sounds, CPM (continuous passive motion) on. While assessing lung sounds and the
use of CPM after knee replacement is essential, it may not be the most critical information to document in the client's electronic medical record (EMR) compared to other potential complications.
Choice B rationale:
Call bell, side rails, bed in low position, and ambulation aids. These are important safety measures and assistive devices for the client's post-operative recovery. While documenting these measures is important, they are not the most crucial findings to be documented in the EMR.
Choice C rationale:
Paresthesia, paralysis, pedal pulses, pallor, and pain. After a total knee replacement, it is crucial to assess the neurovascular status of the affected leg to identify any potential complications like nerve damage, circulatory impairment, or blood clot formation.
Documenting these assessments in the EMR helps monitor the client's progress and identify any changes that may require immediate intervention.
Choice D rationale:
Blood pressure 138/88, pain scale 7, and respirations 22. While monitoring vital signs and pain levels is important, these parameters are not the top priority in this situation.
Neurovascular assessments are more critical for the early detection of complications.
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