The nurse is caring for a patient with an arteriovenous fistula. What instructions are given to unlicensed assistive personnel regarding the care of this patient?

Check for bleeding at needle insertion sites.

Assess the patient's distal pulses and circulation.

Palpate for thrills and auscultate for bruits every 4 hours.

Avoid taking blood pressure readings in the arm with the fistula.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Checking for bleeding at needle insertion sites is a nursing responsibility, not a task for unlicensed assistive personnel (UAP). It requires assessment and clinical judgment to determine if bleeding is excessive or abnormal.

B. Assessing distal pulses and circulation also requires advanced clinical skills and should be performed by a licensed nurse. UAPs can report observations, but they are not trained to interpret circulatory assessment findings.

C. Palpating for thrills and auscultating for bruits every 4 hours is essential for monitoring fistula patency, but it requires both tactile and auditory assessment skills, which are beyond the UAP scope of practice.

D. Avoiding blood pressure readings in the arm with the fistula is an appropriate instruction for UAPs. Applying a blood pressure cuff can damage the fistula, reduce blood flow, or cause clot formation. This precaution is a key safety measure that UAPs can implement under nursing supervision.

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Correct Answer is ["B","E"]

Explanation

Rationale:
A. Checking blood pressure is important for overall monitoring, but it is not specific to the procedure of peritoneal dialysis or infection prevention during exchanges.
B. Strict hand hygiene before connecting or disconnecting dialysis tubing is essential to prevent peritonitis, a serious complication of peritoneal dialysis.
C. Continuous ambulatory peritoneal dialysis (CAPD) involves multiple exchanges (usually 4–5 times daily), not just once at bedtime.
D. CAPD allows clients to remain ambulatory (moving and doing daily activities) during dwell times; lying down is not required.
E. Daily weight monitoring is necessary to assess fluid balance and detect potential fluid overload or dehydration early.

A. "It is important that I take my antihypertensive medications as directed." B. "I can prevent more damage to my kidneys by managing my blood pressure." C. "I need to see the registered dietitian to discuss limiting my protein intake." D. "I have increased urination at night; I need to drink less fluid during the day."

Correct Answer is D

Explanation

Rationale:
A. The statement reflects accurate understanding. Adherence to prescribed antihypertensive therapy helps prevent further renal damage and cardiovascular complications.
B. Uncontrolled hypertension accelerates kidney damage, so effective blood pressure control is a critical part of renal protection.
C. The statemen demonstrates appropriate understanding. Clients with renal disease benefit from guidance on dietary protein restriction to reduce the buildup of nitrogenous waste products.
D. The statement indicates a need for further teaching. Nocturia in renal disease is due to impaired kidney concentration ability, not excessive daytime fluid intake. Fluid restriction should only occur under provider direction, as limiting fluids inappropriately can lead to dehydration and worsen renal perfusion.

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The nurse is caring for a patient with an arteriovenous fistula. What instructions are given to unlicensed assistive personnel regarding the care of this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who will be performing continuous ambulatory peritoneal dialysis at home. Which of the following statements from the client indicates understanding of this type of dialysis management?

Correct Answer is ["B","E"]

Explanation

After teaching a client with hypertension secondary to renal disease, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?

Correct Answer is D

Explanation

The nurse is caring for four clients with chronic kidney disease (CKD). Which client would the nurse assess first upon initial rounding?

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A nurse is providing discharge teaching for a client who is to perform peritoneal dialysis at home. Which of the following information should the nurse include?

The nurse administers epoetin alfa to a client who has chronic kidney disease (CKD). Which laboratory test value would the nurse monitor to determine this drug's effectiveness?