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 D
Explanation
Choice A reason: Feeding the client soft foods is not necessary after cataract surgery. Cataract surgery does not affect the client's ability to eat regular foods, and a normal diet can be resumed unless otherwise instructed by the healthcare provider.
Choice B reason: Positioning the client on the affected side is contraindicated after cataract surgery because it can increase pressure on the eye and disrupt the healing process. Clients are usually advised to avoid sleeping on the side of the operated eye to prevent complications.
Choice C reason: It is not necessary for the client to remain in bed for 3 days following cataract surgery. Clients are encouraged to resume normal activities as tolerated, but they should avoid strenuous activities and heavy lifting to prevent increased intraocular pressure.
Choice D reason: The correct answer is d because wearing dark glasses while outdoors helps protect the eyes from bright light and UV rays, which can cause discomfort and harm the healing eye after cataract surgery.
Correct Answer is C
Explanation
Choice A reason: Providing a diet high in protein is not appropriate during the oliguric phase of acute kidney injury, as it can increase the workload on the kidneys and worsen kidney function. Protein intake should be carefully managed based on the client's condition.
Choice B reason: Ibuprofen is contraindicated in clients with acute kidney injury because it can further impair kidney function. Pain management should be approached with alternative medications that do not have nephrotoxic effects.
Choice C reason: The correct answer is c because monitoring intake and output hourly is crucial in managing acute kidney injury. Accurate measurement of fluid balance helps guide treatment decisions and prevent complications such as fluid overload or dehydration.
Choice D reason: Encouraging the client to consume at least 2 L of fluid daily is not appropriate in the oliguric phase, as the kidneys' ability to excrete fluids is impaired. Fluid intake should be carefully restricted and monitored to avoid fluid overload.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.