The nurse is caring for a client with End Stage Renal Disease has a mature Arteriovenous Fistula. Which of the following interventions would the nurse include in the client's plan of care?
Select All that Apply

Avoid drawing blood from the affected extremity

Auscultate the fistula for the sound of a bruit

Palpate the site to identify the presence of a thrill

Irrigate the fistula with saline to maintain patency

Keep the fistula clamped until ready to perform dialysis

Answer and Explanation

Correct Answer : A,B,C

A. Avoid drawing blood from the affected extremity: Blood draws, IVs, and BP measurements should never be done on the fistula arm to prevent damage and thrombosis.

B. Auscultate the fistula for the sound of a bruit: A bruit (whooshing sound) confirms blood flow through the fistula, indicating patency.

C. Palpate the site to identify the presence of a thrill: A thrill (vibration) should be felt over the fistula. Absence may indicate clotting or failure.

D. Irrigate the fistula with saline to maintain patency: A fistula is never irrigated. Only dialysis staff should access it.

E. Keep the fistula clamped until ready to perform dialysis: AV fistulas are not clamped. Clamping could obstruct blood flow.

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Correct Answer is B

Explanation

A. Blood-tinged: Pancreatic cancer does not typically cause rectal bleeding.

B. Clay: Blockage of the bile duct leads to pale (clay-colored) stools due to lack of bilirubin.

C. Brown: Normal stools are brown due to bilirubin metabolism.

D. Chalky: Chalky is not a typical term used for stool description in pancreatic cancer.

A. Maintain a patent airway and prevent aspiration B. Monitor the effects of ant-hypertensive medications C. Prepare the client for immediate portal shunting surgery D. Perform fecal occult testing on all stools

Correct Answer is B

Explanation

A. Maintain a patent airway and prevent aspiration: While maintaining a patent airway is always important, esophageal varices do not typically cause aspiration unless they rupture. This choice would be a priority in an acute bleed, not in a stable client.

B. Monitor the effects of antihypertensive medications: Beta-blockers (e.g., propranolol) are commonly prescribed to reduce portal hypertension, preventing variceal rupture. Monitoring the effects of these medications is crucial in maintaining hemodynamic stability.

C. Prepare the client for immediate portal shunting surgery: Surgical shunting is considered for refractory cases with severe, recurrent bleeding. A client with stable varices does not require immediate surgery.

D. Perform fecal occult testing on all stools: Esophageal varices cause upper GI bleeding, which manifests as hematemesis or melena, not occult blood in the stool.

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The nurse is caring for a client with End Stage Renal Disease has a mature Arteriovenous Fistula. Which of the following interventions would the nurse include in the client's plan of care? Select All that Apply

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The nurse is caring for a client with End Stage Renal Disease has a mature Arteriovenous Fistula. Which of the following interventions would the nurse include in the client's plan of care?
Select All that Apply