A nurse is caring for a patient with an atrioventricular (AV) fistula in the forearm and assesses that a trill is absent when palpating the venous side of the fistula. What action should the nurse implement?
Inject the ordered amount of heparin into the fistula.
Apply warm compresses and lower the arm below the heart level.
Send the patient to dialysis for remedy.
Report to the charge nurse that the fistula is occluded.
The Correct Answer is D
A. Inject the ordered amount of heparin into the fistula: Heparin is not used to treat occlusion in a fistula without specific orders or a proper diagnostic workup.
B. Apply warm compresses and lower the arm below the heart level: These interventions are not effective for resolving an absent trill in an AV fistula.
C. Send the patient to dialysis for remedy: The absence of a trill requires immediate assessment before considering dialysis treatment.
D. Report to the charge nurse that the fistula is occluded: An absent trill may indicate occlusion or thrombosis of the AV fistula, which requires urgent evaluation and intervention.
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Related Questions
Correct Answer is D
Explanation
A. The antibiotic protocol is completed: While antibiotics may be used for secondary infections, they are not directly related to lifting activity restrictions.
B. Potassium levels are normal: Potassium levels are relevant to kidney function but do not dictate bed rest.
C. Dialysis starts: Dialysis is not typically required in acute glomerulonephritis unless there is severe kidney failure.
D. Blood pressure drops to normal levels: In acute glomerulonephritis, hypertension is a common complication, and activity is often restricted until blood pressure stabilizes.
Correct Answer is A
Explanation
A. Hyperkalemia: Hyperkalemia is the most life-threatening effect of renal failure because elevated potassium levels can cause dangerous cardiac arrhythmias or cardiac arrest.
B. Hypokalemia: Hypokalemia is not commonly associated with renal failure and is less immediately life-threatening than hyperkalemia.
C. Hypernatremia: While fluid imbalances can lead to hypernatremia, it is less critical than hyperkalemia in renal failure.
D. Hyponatremia: Although hyponatremia can occur in renal failure, its effects are typically less acutely life-threatening than hyperkalemia.
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