The nurse is assessing the patency of a client’s left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent?

Palpation of a thrill over the fistula.

Presence of a radial pulse in the left wrist.

Visualization of enlarged blood vessels at the fistula site.

Capillary refill less than 3 seconds in the nail beds of the fingers on the left hand.

Answer and Explanation

The Correct Answer is A

Choice A reason: Palpation of a thrill, a vibrating sensation, indicates blood flow and patency in an arteriovenous fistula. This aligns with hemodialysis access assessment, making it the correct finding the nurse would use to confirm the fistula is patent.

Choice B reason: A radial pulse in the wrist is normal but doesn’t confirm fistula patency, which requires a thrill. Palpation of a thrill is specific, making this incorrect, as it’s not a direct indicator of fistula function in hemodialysis preparation.

Choice C reason: Enlarged vessels may suggest fistula development but don’t confirm active flow. A thrill indicates patency, making this incorrect, as it’s less specific than the nurse’s assessment of a palpable thrill over the fistula site.

Choice D reason: Capillary refill less than 3 seconds assesses distal perfusion, not fistula patency. Palpation of a thrill is the standard, making this incorrect, as it’s unrelated to the nurse’s evaluation of the arteriovenous fistula for hemodialysis.

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Correct Answer is B

Explanation

Choice A reason: A respiratory rate of 10 breaths/min with deep breathing is low but less concerning than 8 breaths/min with snoring, indicating potential airway obstruction. Respiratory depression is the primary opioid risk, making this incorrect compared to the more severe respiratory compromise.

Choice B reason: A respiratory rate of 8 breaths/min with snoring suggests severe opioid-induced respiratory depression, a life-threatening side effect requiring immediate intervention. This aligns with opioid safety monitoring, making it the correct patient most likely experiencing a critical opioid adverse effect.

Choice C reason: Elevated blood pressure and heart rate suggest pain or stress, not respiratory depression, the primary opioid danger. A low respiratory rate with snoring is more critical, making this incorrect, as it doesn’t indicate a life-threatening opioid side effect.

Choice D reason: A temperature of 100.5°F and being easily roused suggest mild fever, not respiratory depression. Snoring with a rate of 8 breaths/min is more dangerous, making this incorrect, as it doesn’t reflect a life-threatening opioid effect in the patient.

A. Initiate seizure precautions. B. Tell the client to report vision changes. C. Elevate the head of the client’s bed. D. Start a peripheral IV.

Correct Answer is D

Explanation

Choice A reason: Seizure precautions are relevant but secondary to establishing IV access for antihypertensive administration in hypertensive crisis. Starting an IV enables immediate treatment, making this incorrect, as it delays the critical intervention needed to lower the client’s dangerously high blood pressure.

Choice B reason: Instructing to report vision changes monitors complications but doesn’t address the urgent need to lower blood pressure. IV access facilitates medication delivery, making this incorrect, as it postpones the primary action for managing the client’s hypertensive crisis effectively.

Choice C reason: Elevating the bed may reduce intracranial pressure but is less urgent than starting an IV for antihypertensive drugs. IV access is the priority, making this incorrect, as it delays the critical intervention to manage the client’s severe hypertension in the emergency department.

Choice D reason: Starting a peripheral IV is the first action to enable rapid administration of antihypertensive medications in hypertensive crisis. This aligns with emergency care protocols for blood pressure 254/139 mm Hg, making it the correct initial step to stabilize the client’s condition.

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The nurse is assessing the patency of a client’s left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

You are taking care of 4 clients who are receiving opioid analgesics for pain management. Which patient is MOST likely to be experiencing a life-threatening opioid side effect?

Correct Answer is B

Explanation

A nurse in an emergency department is caring for a client who has a blood pressure of 254/139 mm Hg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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