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. Increases the appetite: Aluminum hydroxide does not have an appetite-stimulating effect.
B. Corrects the pH of the bowel: Aluminum hydroxide does not directly alter bowel pH; it is used to bind phosphate.
C. Calms the frequent upset stomach experienced by patients on dialysis: Although aluminum hydroxide can reduce stomach acid, its primary use in this context is as a phosphate binder.
D. Binds with phosphorus to increase the serum calcium level: Aluminum hydroxide binds dietary phosphorus in the gastrointestinal tract, reducing serum phosphorus levels. This helps manage the calcium-phosphorus balance, preventing complications like bone demineralization.
Correct Answer is B
Explanation
A. Check for edema of the legs and ankles: Edema is not a common complication of lithotripsy. Monitoring for stone fragments and urinary symptoms is more relevant.
B. Watch for stone debris in the urine in 1 to 4 weeks: Lithotripsy fragments stones, and the patient is expected to pass debris in the urine for several weeks post-procedure.
C. Remain on restricted activity for a week: Patients can usually resume normal activity shortly after lithotripsy unless otherwise instructed.
D. Decrease fluid intake to 1000 mL/day: Increased fluid intake is encouraged to help flush out stone fragments and reduce the risk of recurrence.
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