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: Sitting upright improves breathing but doesn’t address the critical hypoxia indicated by 85% pulse oximetry. Applying oxygen directly corrects low oxygen levels, making this secondary and incorrect compared to the nurse’s priority of ensuring adequate oxygenation in a heart failure exacerbation.

Choice B reason: Calling for intubation anticipates worsening but is premature without first addressing hypoxia with oxygen. Applying oxygen is the immediate need, making this incorrect, as it bypasses the initial step of improving oxygenation in the client with severe respiratory distress.

Choice C reason: Preparing for a Foley catheter anticipates diuresis but doesn’t address the urgent hypoxia at 85% oxygen saturation. Applying oxygen is critical, making this incorrect, as it delays the primary intervention needed to stabilize the client’s respiratory status in heart failure.

Choice D reason: Applying oxygen is the first action to correct hypoxia (pulse oximetry 85%), improving tissue oxygenation in heart failure exacerbation. This aligns with acute care priorities, making it the correct intervention to address the client’s immediate respiratory distress and low oxygen saturation effectively.

A. Monitor the client. B. Elevate the head of the bed. C. Assess the fistula site and dressing. D. Notify the primary health care provider (PHCP).

Correct Answer is D

Explanation

Choice A reason: Monitoring is important but doesn’t address the urgency of headache, nausea, and restlessness, suggesting disequilibrium syndrome. Notifying the provider is critical, making this incorrect, as it delays the nurse’s priority action to manage a serious post-dialysis complication.

Choice B reason: Elevating the head of the bed may help comfort but doesn’t treat potential disequilibrium syndrome indicated by headache and restlessness. Notifying the provider is urgent, making this incorrect, as it’s less critical than the nurse’s need to report symptoms.

Choice C reason: Assessing the fistula site is routine but unrelated to headache and nausea, which suggest a neurological issue. Notifying the provider takes precedence, making this incorrect, as it’s not the priority compared to addressing potential post-dialysis complications.

Choice D reason: Notifying the provider is the priority for headache, nausea, and restlessness post-hemodialysis, as these suggest disequilibrium syndrome, a serious complication. This aligns with dialysis care protocols, making it the correct action for the nurse to take immediately.

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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?

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Correct Answer is D

Explanation

The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action?

Correct Answer is D

Explanation

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