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. "This procedure will cure my liver disease.": Paracentesis does not cure cirrhosis; it only helps manage complications.

B. "This procedure will remove fluid from my abdomen.": The primary purpose of paracentesis is to drain ascitic fluid and relieve abdominal distention, discomfort, and respiratory compromise.

C. "This procedure will help lower my ammonia levels.": Ammonia levels are managed through lactulose therapy and dietary modifications, not paracentesis.

D. "This procedure will help reduce my risk of infection.": While paracentesis may be performed to obtain fluid for infection evaluation (spontaneous bacterial peritonitis), it does not inherently reduce infection risk.

A. Only use a soft-bristle toothbrush B. Apply an ice pack over a bleeding wound C. Use a Boss pick instead of the four string to floss in between the teeth D. Wear sleeveless or short-sleeved shirts and shorts to better visualize any skin issues

Correct Answer is A

Explanation

A. Only use a soft-bristle toothbrush: Clients with thrombocytopenia are at risk for bleeding, including gum bleeding. Using a soft-bristle toothbrush minimizes trauma to the gums and reduces the risk of bleeding.

B. Apply an ice pack over a bleeding wound: While ice can help constrict blood vessels and reduce minor bleeding, it is not the primary preventative measure for thrombocytopenia-related bleeding.

C. Use a floss pick instead of the floss string to clean between teeth: A floss pick may still cause gum trauma. It is recommended to use a soft flossing technique or avoid flossing if platelet counts are extremely low.

D. Wear sleeveless or short-sleeved shirts and shorts to better visualize any skin issues: While monitoring for petechiae or bruising is important, it does not actively prevent bleeding complications.

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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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with cirrhosis is scheduled for a paracentesis. Which of the following statements indicate that the client understands the purpose of the procedure?

Correct Answer is B

Explanation

A nurse is caring for a client who has end-stage liver disease and a recent diagnosis of thrombocytopenia. Which of the following statements provides the best recommendation to prevent complications of bleeding?

Correct Answer is A

Explanation

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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