The nurse is assessing a patient’s arteriovenous (AV) fistula. Which finding provides evidence of its normal function?
Pulselessness.
Ecchymotic area.
Redness.
Enlarged vein.
The Correct Answer is D
Choice A reason: Pulselessness is not a sign of normal AV fistula function; a palpable pulse should be present.
Choice B reason: An ecchymotic area suggests bruising and is not indicative of normal function.
Choice C reason: Redness may indicate inflammation or infection, not normal function.
Choice D reason: This is the correct choice. An enlarged vein is typical for an AV fistula and indicates good blood flow through the fistula.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Non-opioid analgesics are typically not strong enough to manage the severe pain associated with a sickle cell crisis.
Choice B reason: Guided imagery can be a helpful adjunct, but it is not the primary method of pain control during a crisis.
Choice C reason: Diversional activities may help distract from the pain but are not sufficient as the sole method of pain management.
Choice D reason: This is the correct choice. An IV PCA (patient-controlled analgesia) allows the child to manage pain effectively and is appropriate for severe pain during a sickle cell crisis.
Correct Answer is C
Explanation
Choice A reason: Lifting and clearing drainage from the chest tube is not necessary unless there is a blockage, which is not indicated by the water level changes.
Choice B reason: Inspecting the tube insertion site for leaking is important but not related to the observation of water level changes in the water-seal chamber.
Choice C reason: This is the correct choice. The water level rising during inspiration and falling during expiration is a normal finding that indicates the chest tube is functioning properly.
Choice D reason: Auscultating lungs for unequal breath sounds is part of the assessment but does not address the observed water level changes in the water-seal chamber.
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