The charge nurse is orienting a new nurse about care for an assigned client with an arteriovenous (AV) fistula for hemodialysis in her left arm. Which action by the float nurse would be considered unsafe?

Checking distal pulses in the left arm

Using the right arm for a blood pressure reading

Palpating the access site for a bruit or thrill

Administering intravenous fluids through the AV fistula

Answer and Explanation

The Correct Answer is D

Rationale:
A. Checking distal pulses in the left arm is a safe and appropriate nursing action. It helps assess for adequate circulation beyond the AV fistula site and ensures that the vascular access has not compromised blood flow to the distal extremity.

B. Using the right arm for a blood pressure reading is appropriate and safe. Blood pressure measurements, venipunctures, or IV insertions should never be done on the arm with the AV fistula to avoid causing clot formation, vessel damage, or access loss.

C. Palpating the access site for a bruit or thrill is an important routine assessment to verify the patency and proper functioning of the fistula. The presence of a thrill (vibration) and bruit (swishing sound) indicates adequate blood flow through the access.

D. Administering intravenous fluids through the AV fistula is unsafe and contraindicated. The AV fistula must be used only for hemodialysis by trained personnel. Using it for IV fluids or medications increases the risk of infection, thrombosis, or permanent damage to the access site, which could compromise future dialysis treatments.

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Correct Answer is C

Explanation

Rationale:
A. Hypophosphatemia is uncommon in prerenal AKI. Instead, phosphate tends to increase because the kidneys cannot excrete it effectively.
B. Hypercalcemia is not typically seen in AKI. In fact, hypocalcemia is more common due to phosphate retention and reduced activation of vitamin D by the damaged kidneys.
C. Hyperkalemia is a characteristic finding in acute kidney injury (AKI), including prerenal AKI, because the kidneys’ impaired perfusion and filtration lead to decreased potassium excretion. As potassium accumulates in the blood, clients are at risk for cardiac dysrhythmias and cardiac arrest, making this an urgent condition that requires close monitoring and prompt management.
D. Hypernatremia is not typically associated with prerenal AKI. Instead, hyponatremia or normal sodium levels are more common due to fluid retention and dilutional effects.

A. Pyelonephritis B. Kidney stones C. Dehydration D. Bladder cancer

Correct Answer is C

Explanation

Rationale:
A. Pyelonephritis is an infection of the renal pelvis and kidney tissue, which leads to intrarenal (not prerenal) damage due to inflammation and infection within the kidneys.

B. Kidney stones obstruct urine flow and cause postrenal AKI, not prerenal. This type of injury occurs after the urine leaves the kidneys, leading to back pressure and impaired excretion.

C. Dehydration leads to reduced blood flow to the kidneys, decreasing glomerular filtration rate (GFR) and causing prerenal AKI. Prerenal injury results from conditions that impair perfusion, such as hypovolemia, hemorrhage, or hypotension.

D. Bladder cancer can cause postrenal AKI by obstructing the urinary outflow tract, but it does not affect renal perfusion directly, so it is not a prerenal cause.

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The charge nurse is orienting a new nurse about care for an assigned client with an arteriovenous (AV) fistula for hemodialysis in her left arm. Which action by the float nurse would be considered unsafe?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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