A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency?
Cold and numb sensation distal to the fistula site
A raised red rash around the fistula site
Pain in the right arm proximal to the fistula site
Foul-smelling drainage from the fistula site
The Correct Answer is A
Choice A: Cold and numb sensation distal to the fistula site is a possible indication of venous insufficiency. Venous insufficiency is a condition in which the veins have difficulty returning blood from the limbs to the heart, resulting in blood pooling and reduced perfusion. A new arteriovenous fistula can cause increased blood flow through the artery and decreased blood flow through the vein, leading to venous insufficiency. This can manifest as coldness, numbness, tingling, or cyanosis in the fingers or hand below the fistula site.
Choice B: A raised red rash around the fistula site is not a possible indication of venous insufficiency. A raised red rash around the fistula site can indicate an allergic reaction, an infection, or an inflammation of the skin or subcutaneous tissue. The nurse should assess the rash for size, shape, color, texture, temperature, and drainage, and report any signs of infection or inflammation, such as fever, pus, or swelling.
Choice C: Pain in the right arm proximal to the fistula site is not a possible indication of venous insufficiency. Pain in the right arm proximal to the fistula site can indicate arterial insufficiency, which is a condition in which the arteries have difficulty delivering oxygen-rich blood to the tissues, resulting in ischemia and necrosis. Arterial insufficiency can be caused by atherosclerosis, thrombosis, embolism, or vasospasm. The nurse should assess the pain for location, intensity, duration, frequency, and quality, and report any signs of ischemia or necrosis, such as pallor, coolness, weak pulses, or ulceration.
Choice D: Foul-smelling drainage from the fistula site is not a possible indication of venous insufficiency. Foul-smelling drainage from the fistula site can indicate an infection of the fistula or surrounding tissue. The nurse should assess the drainage for color, odor, amount, and consistency, and report any signs of infection or sepsis, such as fever, chills, malaise, or hypotension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is: C. Continue the rate at 125 mL/hr.
Choice A: Slow the rate to 50 mL/hr
Slowing the IV fluid rate to 50 mL/hr is not appropriate for a patient with a head injury. Adequate fluid management is crucial to maintain cerebral perfusion pressure and prevent secondary brain injury. Reducing the rate to 50 mL/hr could lead to hypovolemia, which might decrease cerebral perfusion and worsen the patient’s condition.
Choice B: Slow the rate to 20 mL/hr
Slowing the IV fluid rate to 20 mL/hr is even less appropriate. Such a low rate would likely result in significant hypovolemia, severely compromising cerebral perfusion pressure. This could exacerbate the patient’s head injury by reducing the blood flow to the brain, leading to further damage.
Choice C: Continue the rate at 125 mL/hr
Continuing the rate at 125 mL/hr is appropriate. This rate helps maintain euvolemia, which is essential for ensuring adequate cerebral perfusion pressure in patients with head injuries. Maintaining a stable fluid rate helps prevent both hypovolemia and hypervolemia, both of which can negatively impact intracranial pressure and cerebral perfusion.
Choice D: Increase the rate to 250 mL/hr
Increasing the IV fluid rate to 250 mL/hr is not recommended. Overhydration can lead to increased intracranial pressure, which can be detrimental to a patient with a head injury. Excessive fluid administration can cause cerebral edema, worsening the patient’s condition.
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because magnesium is not a medication for symptomatic bradycardia. Magnesium is a mineral that regulates muscle and nerve function, blood pressure, and blood sugar levels. Magnesium can be used to treat conditions such as torsades de pointes, eclampsia, or hypomagnesemia.
Choice B Reason: This is incorrect because sodium bicarbonate is not a medication for symptomatic bradycardia. Sodium bicarbonate is a substance that neutralizes acids and bases and regulates the pH of the blood. Sodium bicarbonate can be used to treat conditions such as metabolic acidosis, cardiac arrest, or overdose of certain drugs.
Choice C Reason: This is incorrect because epinephrine is not a medication for symptomatic bradycardia. Epinephrine is a hormone that activates the sympathetic nervous system and increases the heart rate, blood pressure, and blood flow to the muscles and brain. Epinephrine can be used to treat conditions such as anaphylaxis, cardiac arrest, or severe asthma.
Choice D Reason: This is correct because atropine is a medication for symptomatic bradycardia. Atropine blocks the action of the parasympathetic nervous system and increases the heart rate and conduction. Atropine is a medication that blocks the action of the parasympathetic nervous system and increases the heart rate and conduction.
Symptomatic bradycardia is a condition where the heart rate is slower than normal and causes symptoms such as dizziness, fatigue, chest pain, or fainting. Atropine can be used to treat symptomatic bradycardia by stimulating the sinoatrial node and the atrioventricular node, which are the natural pacemakers of the heart.
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