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 D

Explanation

Choice A reason: Antibiotics treat infection, but fever, tenderness, and rising creatinine suggest rejection, not infection. Immunosuppression addresses rejection, making this incorrect, as it’s less likely than the nurse’s anticipation of therapy to manage transplant rejection in the client.

Choice B reason: Peritoneal dialysis is used for kidney failure, not acute transplant rejection, which causes fever and creatinine rise. Immunosuppression is needed, making this incorrect, as it’s irrelevant to the nurse’s expected treatment for the client’s post-transplant symptoms.

Choice C reason: Removing the kidney is a last resort, not the first response to rejection signs like fever and tenderness. Increased immunosuppression is standard, making this incorrect, as it’s premature compared to the nurse’s anticipation of rejection management.

Choice D reason: Increased immunosuppression treats acute transplant rejection, indicated by fever, tenderness, rising creatinine, and kidney enlargement. This aligns with post-transplant care, making it the correct treatment the nurse would anticipate for the client’s symptoms one week after transplantation.

A. Testing skin turgor. B. Assessing cognition. C. Monitoring urine output. D. Checking deep tendon reflexes. E. Asking about any abdominal pain. F. Checking for the presence of fever.

Correct Answer is ["B","C","D"]

Explanation

Choice A reason: Testing skin turgor assesses dehydration, not severe hyponatremia (118 mEq/L), which affects neurological status. Assessing cognition detects complications, making this incorrect, as it’s less critical than the nurse’s priority of monitoring for hyponatremia’s neurological and fluid effects.

Choice B reason: Assessing cognition is critical with a sodium level of 118 mEq/L, as severe hyponatremia causes confusion or seizures. This aligns with neurological assessment, making it a correct action the nurse should perform to prevent harm in the hyponatremic client.

Choice C reason: Monitoring urine output tracks fluid balance, vital in hyponatremia to assess for SIADH or fluid overload. This aligns with renal assessment, making it a correct action the nurse should perform to prevent harm in the client with severe hyponatremia.

Choice D reason: Checking deep tendon reflexes detects neurological changes from hyponatremia, such as hyporeflexia or seizures. This aligns with neurological monitoring, making it a correct assessment the nurse should perform to prevent harm in the client with a sodium of 118 mEq/L.

Choice E reason: Abdominal pain is unrelated to hyponatremia, which primarily affects the brain and fluid balance. Monitoring urine output is more relevant, making this incorrect, as it’s not a priority assessment for the nurse to prevent harm in the hyponatremic client.

Choice F reason: Fever may indicate infection but isn’t directly linked to hyponatremia’s neurological risks. Assessing cognition is critical, making this incorrect, as it’s less urgent than the nurse’s focus on preventing harm from severe hyponatremia’s neurological complications.

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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

Correct Answer is D

Explanation

Which assessments are most important for the nurse to perform to prevent harm on a client with a sodium level of 118 mEq/L (mmol/L)? (Select all that apply)

Correct Answer is ["B","C","D"]

Explanation

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