A nurse is caring for a client post hemodialysis. The nurse assesses bleeding at the AV fistula site, the nurse should prioritize which of the following actions?

Obtain a complete blood count (CBC)

Start IV fluids

Apply direct pressure

Administer pain medication

Answer and Explanation

The Correct Answer is C

A. Obtain a complete blood count (CBC): This is not the immediate action in an active bleeding scenario.

B. Start IV fluids: This may be needed later if significant blood loss occurs, but not the first response.

C. Apply direct pressure: Bleeding from a fistula requires immediate direct pressure to prevent blood loss and preserve vascular access.

D. Administer pain medication: Pain management is important but not the priority in acute bleeding.

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Correct Answer is D

Explanation

A. Decreased serum sodium: Kayexalate exchanges sodium for potassium, so sodium may actually increase.

B. Decreased serum phosphorus: Kayexalate does not directly affect phosphate levels.

C. Decreased urine specific gravity: Kayexalate does not influence urine output or concentration.

D. Decreased serum potassium: Kayexalate treats hyperkalemia by exchanging potassium ions for sodium in the intestines, lowering serum potassium.

A. Urinary output 25 mL/hr B. Heart rate 122/min C. Pain of 6 on a scale of 0 to 10 D. Difficulty swallowing secretions

Correct Answer is D

Explanation

A. Urinary output 25 mL/hr: This is below normal, but not an immediate airway threat.

B. Heart rate 122/min: Elevated HR is common in burns due to fluid shifts and stress.

C. Pain of 6 on a scale of 0 to 10: Pain is expected but not life-threatening.

D. Difficulty swallowing secretions: Indicates possible airway edema or inhalation injury, which can progress to airway obstruction. This is a medical emergency.

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A nurse is caring for a client post hemodialysis. The nurse assesses bleeding at the AV fistula site, the nurse should prioritize which of the following actions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client receiving sodium polystyrene sulfonate (Kayexalate) for the treatment of chronic renal disease. The nurse should monitor for which therapeutic effect of sodium polystyrene sulfonate (Kayexalate)?

Correct Answer is D

Explanation

A nurse is assessing a client with burns to the face, ears, and eyelids. The nurse should identify which of the following as the priority finding to report to the provider?

Correct Answer is D

Explanation

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