A client with a history of chronic renal failure receives hemodialysis treatment three times per week through an arteriovenous (AV) fistula in the left arm. Which priority intervention should the nurse include in the care plan?

Take the client’s blood pressure in the left arm

Keep the AV fistula site dry

Keep the AV fistula wrapped in gauze

Assess the AV fistula for bruit and thrill

Answer and Explanation

The Correct Answer is D

Choice A reason: Taking blood pressure in the left arm with an AV fistula risks compressing the fistula, potentially causing thrombosis or damage. This can impair dialysis access, leading to inadequate treatment and complications like uremia or fluid overload. Blood pressure should be measured in the opposite arm to protect the fistula.

Choice B reason: Keeping the AV fistula site dry is important to prevent infection, as moisture can promote bacterial growth. However, it is not the priority over ensuring fistula patency, which is critical for effective dialysis. Infection prevention is secondary to confirming the fistula’s functionality to avoid life-threatening dialysis interruptions.

Choice C reason: Wrapping the AV fistula in gauze is not standard practice unless post-surgical or infected. Excessive wrapping may obscure the site, hindering patency assessments, and could increase infection risk if not changed properly. This action is less critical than ensuring the fistula’s functionality for dialysis.

Choice D reason: Assessing the AV fistula for bruit (whooshing sound) and thrill (vibration) confirms patency, ensuring it is functional for dialysis. A non-patent fistula prevents effective toxin and fluid removal, leading to uremia, hyperkalemia, or fluid overload. This assessment is the priority to ensure life-sustaining dialysis can proceed without complications.

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Correct Answer is A

Explanation

Choice A reason: In the oliguric phase of AKI, kidney function is severely impaired, reducing potassium excretion. This leads to hyperkalemia, which disrupts cardiac electrical activity, potentially causing life-threatening arrhythmias or cardiac arrest. Elevated potassium levels are a hallmark of this phase due to decreased glomerular filtration rate and impaired tubular secretion.

Choice B reason: Urine output of 2000 mL in 24 hours indicates polyuria, characteristic of the recovery phase of AKI, not the oliguric phase, where output is typically less than 400 mL/day. High urine output suggests restored renal function, which is not expected in the oliguric phase, where kidneys fail to filter adequately.

Choice C reason: Tachycardia may occur in AKI due to fluid overload causing increased cardiac workload or electrolyte imbalances like hyperkalemia affecting heart rhythm. However, it is a secondary symptom and less specific than hyperkalemia, which directly results from impaired renal excretion and poses a more immediate risk to cardiac function.

Choice D reason: Tenting of the skin indicates dehydration, which may precede AKI but is not typical in the oliguric phase, where fluid retention is more common due to reduced urine output. Fluid overload leads to edema, not dehydration, making skin tenting an unlikely finding in this phase of AKI.

A. Sitting upright, uncrossed legs and arms, and at eye level B. Leaning forward with arms placed on a table sitting directly across from the client C. Sitting upright facing the client with both feet on the floor D. Turned slightly to the side of the client with arms folded across the chest

Correct Answer is A

Explanation

Choice A reason: Sitting upright with uncrossed limbs at eye level conveys openness and engagement. Uncrossed arms and legs signal non-defensiveness, while eye-level positioning fosters equality and trust. This posture aligns with therapeutic communication principles, promoting a safe, accepting environment for the client to express emotions freely.

Choice B reason: Leaning forward with arms on a table may appear intrusive or aggressive, potentially making the client feel uncomfortable. While engagement is intended, this posture can reduce personal space, disrupting the therapeutic environment and hindering the client’s sense of safety and acceptance during the conversation.

Choice C reason: Sitting upright with feet on the floor is neutral but less specific in conveying acceptance. Without mention of uncrossed arms or eye-level positioning, it may not fully signal openness. While not negative, it lacks the full therapeutic posture needed to maximize client comfort and trust.

Choice D reason: Turning to the side with folded arms suggests defensiveness or disengagement, which can make the client feel unaccepted or dismissed. This posture contradicts therapeutic communication principles, as it creates a barrier to open dialogue and may hinder the client’s willingness to share emotions.

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A client with a history of chronic renal failure receives hemodialysis treatment three times per week through an arteriovenous (AV) fistula in the left arm. Which priority intervention should the nurse include in the care plan?

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