A nurse is monitoring a client following a hemodialysis treatment through an arteriovenous (AV) fistula. Which of the following findings should the nurse report to the provider?
Blood pressure 134/82 mm Hg
Headache, restlessness
Palpable thrill at the AV fistula access site
Heart rate 65 bpm
The Correct Answer is B
Choice A reason: A blood pressure of 134/82 mm Hg is within the normal range and typically does not require immediate intervention. It is important to monitor blood pressure trends, but this value alone is not concerning.
Choice B reason: The correct answer is b because headache and restlessness can be signs of dialysis-related complications such as disequilibrium syndrome or fluid and electrolyte imbalances. These symptoms should be reported to the provider for further evaluation and management.
Choice C reason: A palpable thrill at the AV fistula access site indicates that the fistula is functioning properly. This is an expected finding and does not require intervention.
Choice D reason: A heart rate of 65 bpm is within the normal range for most adults and does not typically require immediate intervention unless associated with other symptoms or abnormalities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Black-colored stools can indicate gastrointestinal bleeding, which is a potential side effect of corticosteroids like betamethasone. It is not considered harmless and should be reported to the healthcare provider immediately.
Choice B reason: A low-potassium diet is not specifically required for clients taking betamethasone. Corticosteroids can cause potassium loss, so it is important to monitor potassium levels, but not necessarily restrict intake unless directed by the healthcare provider.
Choice C reason: The correct answer is c because taking corticosteroids like betamethasone every other day can help reduce the risk of adrenal suppression, a common side effect of long-term corticosteroid use. This dosing schedule allows the adrenal glands to recover and maintain their function.
Choice D reason: Taking betamethasone before bedtime is not specifically recommended for its effectiveness. The dosing schedule should be based on the healthcare provider's instructions and tailored to the client's condition and response to the medication.
Correct Answer is B
Explanation
Choice A reason: Uncontrolled hypertension is a significant risk factor for hemorrhagic stroke rather than ischemic embolic stroke. Hypertension can lead to the rupture of blood vessels in the brain, causing bleeding.
Choice B reason: The correct answer is b because chronic atrial fibrillation increases the risk of embolic stroke. In atrial fibrillation, the irregular heartbeat can lead to the formation of blood clots in the atria. These clots can travel to the brain and cause an ischemic stroke by blocking blood flow.
Choice C reason: Thrombocytopenia, characterized by low platelet count, primarily affects clotting and bleeding tendencies rather than directly increasing the risk of embolic stroke. It can, however, complicate the management of stroke due to bleeding risks.
Choice D reason: An arteriovenous malformation (AVM) is a tangle of abnormal blood vessels connecting arteries and veins in the brain. While AVMs can increase the risk of hemorrhagic stroke, they are not typically associated with ischemic embolic stroke.
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