A client on hemodialysis has a history of arteriovenous (AV) fistula creation. Which of the following assessments should the nurse perform to ensure proper functioning of the AV fistula?
Palpate for a thrill or vibration over the AV fistula site.
Auscultate for bruits over the radial artery.
Check for distal pulses in the lower extremities.
Assess for swelling and tenderness in the neck.
The Correct Answer is A
A) This statement is accurate. Palpating for a thrill or vibration over the AV fistula site is a critical assessment to ensure proper functioning. A thrill indicates adequate blood flow through the fistula, which is essential for effective hemodialysis.
B) This statement is incorrect. Auscultating for bruits over the radial artery is not related to the AV fistula assessment. The bruit is the sound of blood flow in the fistula, which is best assessed directly over the fistula site.
C) This statement is incorrect. Checking for distal pulses in the lower extremities is not related to the assessment of an AV fistula. The AV fistula is typically created in the upper extremity.
D) This statement is incorrect. Assessing for swelling and tenderness in the neck is not related to the AV fistula assessment. Swelling and tenderness may be related to other issues but are not specific to AV fistula functioning.
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Related Questions
Correct Answer is A
Explanation
A) The client's symptoms of dizziness and weakness may indicate hypotension (low blood pressure). The nurse should first check the client's blood pressure and pulse rate to assess for hypotension before implementing further interventions.
B) This statement is incorrect. Administering an antiemetic medication would not address the reported symptoms of dizziness and weakness, which may be related to changes in blood pressure.
C) This statement is incorrect. Increasing the rate of fluid removal during dialysis may exacerbate the client's symptoms of dizziness and weakness and may lead to hypotension (low blood pressure).
D) This statement is incorrect. Elevating the client's legs may help improve blood flow, but it does not address the underlying cause of the reported symptoms. The nurse should first check the client's blood pressure and pulse rate to assess for hypotension before implementing further interventions.
Correct Answer is C
Explanation
A) This statement is incorrect. Peritoneal dialysis does not require extended hospital stays, as it can be performed at home.
B) This statement is incorrect. While some modifications to daily activities may be necessary, peritoneal dialysis does not generally require clients to limit their daily activities or avoid physical exertion.
C) This statement is accurate. Peritoneal dialysis is a form of dialysis that can be performed by the client at home, allowing them to continue with their daily activities without the need for hospitalization or daily clinic visits.
D) This statement is incorrect. Peritoneal dialysis is performed by the client at home, not at the outpatient clinic every day. The client may visit the clinic for periodic follow-up and assessment, but the actual dialysis is performed at home.
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