A nurse is assessing a client with an AV fistula. Which of the following assessments should the nurse perform to evaluate the function of the AV fistula? (Select All that Apply.)
Observe the client's skin color and temperature in the affected arm
Measure the blood pressure in the affected arm
Auscultate for the presence of a bruit over the fistula
Palpate the fistula for a thrill
Assess the client's cognitive status
Assess the client's respiratory rate
Correct Answer : A,C,D
A: Monitoring the skin color and temperature can help identify complications such as thrombosis or infection in the fistula arm.
B: Blood pressure measurement in the fistula arm should be avoided because it may cause damage to the fistula.
C: A bruit indicates proper blood flow through the fistula, which is essential for function.
D: A thrill is a palpable vibration that should be present if the fistula is functioning correctly.
E: Cognitive status is not relevant to evaluating the function of the AV fistula.
F: Respiratory rate is unrelated to assessing the fistula's function.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Decreased blood pressure and a rapid pulse are signs of hemodynamic instability, but they do not specifically indicate the need for phenytoin.
B. Pain and tingling at the access site are not related to seizures.
C. Headache and restlessness can be early signs of seizures or seizure activity, and phenytoin is indicated for seizure prevention and treatment.
D. Muscle cramps and chest heaviness are common symptoms of dialysis but are not indications for phenytoin.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}
Explanation
Review mandatory nursing skills and competencies: This topic is a general unit-wide requirement, so it should be discussed in the unit meeting to ensure all nurses are informed of the schedule and importance of maintaining competencies.
Review central line infections rates: This is a quality and safety issue affecting the entire unit. All team members should be aware of infection control practices, so it is appropriate for the unit meeting.
Disruptive behavior incident: Since disruptive behavior affects the unit's work environment and patient care, the nurse manager should include a review of this issue in the meeting. This provides an opportunity to educate the team about maintaining professionalism and civility.
Near miss fall: Fall prevention and safety are critical topics for the entire team. This should be covered in the unit meeting to reinforce safety protocols and discuss strategies to prevent future incidents.
Mislabeled specimen: This issue involves a specific individual (T.J., the AP), and corrective actions should be taken with them. The nurse manager should meet privately with T.J. to discuss the repeated errors, reinforce the importance of accuracy in specimen labeling, and review policies and procedures.
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