The nurse is assessing a patient’s arteriovenous (AV) fistula. Which finding provides evidence of its normal function?

Pulselessness.

Ecchymotic area.

Redness.

Enlarged vein.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Fasciitis, inflammation of the fascia, could cause pain and possibly edema, but it typically does not cause fever.

Choice B reason: Compartment syndrome is a serious condition where increased pressure within the muscles can lead to muscle and nerve damage as well as problems with blood flow. Pain, edema, and fever could be signs of this condition, especially in a limb that is in traction.

Choice C reason: Osteochondrosis refers to a group of disorders that affect the growth of bones in children and adolescents. While it can cause pain, it does not typically cause edema or fever.

Choice D reason: Osteomyelitis, an infection in the bone, could cause pain, edema, and fever. However, the acute onset of symptoms in a limb under traction is more indicative of compartment syndrome. Osteomyelitis typically has a more gradual onset.

A. Symptoms of infection B. Anaphylaxis C. Pain at the injection site D. Myalgia E. Hyperthermia

Correct Answer is B

Explanation

Choice A reason: While symptoms of infection are important to assess, they are not the immediate priority following vaccine administration.

Choice B reason: Anaphylaxis is a rapid, potentially life-threatening allergic reaction that can occur after vaccination, making it the priority assessment.

Choice C reason: Pain at the injection site is common and expected, but it is not as critical as assessing for anaphylaxis.

Choice D reason: Myalgia, or muscle pain, may occur after vaccination but is not the immediate priority for assessment.

Choice E reason: Hyperthermia, or elevated body temperature, could indicate an adverse reaction; however, anaphylaxis is the most urgent concern to address post-vaccination.

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The nurse is assessing a patient’s arteriovenous (AV) fistula. Which finding provides evidence of its normal function?

Nursing Test Bank

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