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 A
Explanation
Choice A: Fatigue is a manifestation that the nurse should identify as indicating the client is hypokalemic. Hypokalemia is a condition in which the blood potassium level is lower than normal, usually due to excessive loss of potassium through urine, sweat, or vomiting. Potassium is an electrolyte that is essential for nerve and muscle function, especially for the heart. Hypokalemia can cause muscle weakness, cramps, and fatigue, as well as cardiac arrhythmias and dysrhythmias.
Choice B: Dyspnea is not a manifestation that the nurse should identify as indicating the client is hypokalemic. Dyspnea is a sensation of difficulty breathing or shortness of breath. Dyspnea can be caused by various conditions, such as asthma, chronic obstructive pulmonary disease (COPD), pneumonia, or pulmonary edema. Dyspnea is not directly related to hypokalemia, but it can be a sign of heart failure, which can cause fluid accumulation in the lungs and impair gas exchange.
Choice C: Oliguria is not a manifestation that the nurse should identify as indicating the client is hypokalemic. Oliguria is a reduced urine output, usually less than 400 mL per day or 30 mL per hour. Oliguria can be caused by various conditions, such as dehydration, kidney failure, urinary tract obstruction, or shock. Oliguria is not directly related to hypokalemia, but it can be a sign of kidney damage or impairment, which can affect electrolyte balance and fluid volume.
Choice D: Pitting edema is not a manifestation that the nurse should identify as indicating the client is hypokalemic. Pitting edema is a swelling of the tissues that leaves an indentation when pressed with a finger. Pitting edema can be caused by various conditions, such as venous insufficiency, lymphedema, liver cirrhosis, or malnutrition. Pitting edema is not directly related to hypokalemia, but it can be a sign of heart failure, which can cause fluid retention and overload in the body.
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because droplet precautions are not sufficient to prevent the transmission of pneumonic plague. Droplet precautions are used to prevent the spread of infectious agents that are expelled through coughing, sneezing, or talking and travel only a short distance in the air. Droplet precautions include wearing a surgical mask, gown, and gloves, and placing the client in a private room or with a roommate who has the same infection.
Choice B Reason: This is incorrect because administering an antitoxin is not an intervention for pneumonic plague. An antitoxin is a substance that neutralizes the effects of a toxin produced by a microorganism. Pneumonic plague is not caused by a toxin, but by a bacterial infection.
Choice C Reason: This is correct because initiating airborne precautions is an intervention for pneumonic plague. Airborne precautions are used to prevent the spread of infectious agents that can remain suspended in the air and travel over long distances. Pneumonic plague is a severe and potentially fatal infection caused by the bacterium Yersinia pestis, which can be transmited through respiratory droplets or aerosols. Airborne precautions are used to prevent the spread of infectious agents that can remain suspended in the air and travel over long distances. Airborne precautions include wearing a respirator or N95 mask, placing the client in a negative-pressure room with an air filtration system, and limiting visitors and staff contact.
Choice D Reason: This is incorrect because destroying the linens after use is not an intervention for pneumonic plague. Linens that are contaminated with body fluids or secretions should be handled with gloves and placed in leak-proof bags for laundering or disposal, but they do not need to be destroyed.
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