A client with chronic kidney disease (CKD) has an arteriovenous (AV) fistula in the left forearm. Which observation by the nurse indicates that the fistula is patent? Select all that apply.
The left radial pulse is 2+ bounding.
Distended, tortuous veins in the left hand.
Auscultation of a thrill on the left forearm.
Assessment of a bruit on the left forearm.
Correct Answer : D
A. A bounding radial pulse does not specifically indicate the patency of an AV fistula; it is a general assessment of peripheral pulse quality.
B. Distended veins in the hand may indicate venous congestion but are not a reliable indicator of fistula patency.
C. A "thrill" is a vibratory sensation felt over the fistula. It is caused by the turbulent blood flow moving from the high-pressure artery into the lower-pressure vein. However, this choice is wrong since a thrill should be palpated and not auscultated.
D. The presence of a bruit (a whooshing sound) over the AV fistula indicates the flow of blood through the fistula, confirming patency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Calculating the G-T-P-A-L Designation:
G (Gravida): 5 (current pregnancy + 4 previous pregnancies)
T (Term births): 2 (one singleton at 38 weeks and one singleton at 41 weeks)
P (Preterm births): 1 (twins at 35 weeks)
A (Abortions): 1 (spontaneous abortion at 10 weeks)
L (Living children): 4 (the three children born and the current pregnancy)
Correct Answer is C
Explanation
A.An auscultatory gap is a period of silence that occurs between systolic and diastolic sounds (often seen in hypertensive patients). You cannot confirm a gap exists until you have completed the entire deflation and noted if sounds disappear and then reappear.
B. Since the nurse already heard a Korotkoff sound, the stethoscope is correctly placed over the brachial artery. Moving it now would interrupt the reading.
C. When performing manual blood pressure measurement, the transition from silence to the first rhythmic tapping sound indicates the systolic blood pressure (Phase I of Korotkoff sounds). Hearing silence followed by a clear sound after the valve has been released is the expected progression of the procedure.
D.Reinflating the cuff immediately on the same arm can cause venous congestion, leading to an inaccurate (falsely high) diastolic reading. If a reading must be repeated, the nurse should deflate the cuff completely and wait 1 to 2 minutes before trying again.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.