The nurse is providing education to the client with a new arteriovenous fistula and the client asks "when I touch my fistula feel it vibrate, what does that mean? What statement by the nurse is the correct way to answer the client's question?
“This is called a thrill and it means that your fistulas not working.”
"This is not a normal sign will call your provider right away.”
"This is called a bruit and it shows that your fistula patent."
“This is called a thrill and it means that your fistula is patent.”
The Correct Answer is D
A. “This is called a thrill and it means that your fistula is not working.” A thrill is a normal finding and means the fistula is functioning properly.
B. "This is not a normal sign; we will call your provider right away.” A lack of thrill is abnormal, not the presence of one.
C. "This is called a bruit and it shows that your fistula is patent." The thrill is felt and the bruit is heard.
D. "This is called a thrill and it means that your fistula is patent." A thrill (vibration) is a normal finding in an AV fistula and indicates adequate blood flow. A bruit (whooshing sound) is heard on auscultation and also confirms patency.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "I can’t wait to start back to work next week, I really need the money." Returning to work too soon increases the risk of infection and complications. Clients should follow their provider's recommendations.
B. "I will follow my 1,500 mL fluid restriction." After a kidney transplant, patients typically need increased fluid intake to maintain kidney perfusion, not restriction.
C. "I will take my temperature and if it is above 101°F, I will call my doctor." Fever >101°F (38.3°C) is an early sign of infection or organ rejection. Prompt medical attention is required.
D. "I am glad I won't have to keep track of how much I urinate in the day." Clients must monitor urine output to detect signs of kidney rejection or dysfunction.
Correct Answer is A
Explanation
A. Chloride level would be decreased: Metabolic alkalosis is often associated with hypochloremia, especially when caused by vomiting or diuretics. However, hypokalemia is more clinically significant.
B. Sodium level would be elevated: Sodium levels are not directly affected by metabolic alkalosis.
C. Magnesium level would be elevated: Magnesium levels are not significantly altered in metabolic alkalosis.
D. Potassium level would be decreased: A bicarbonate level of 30 mEq/L indicates metabolic alkalosis. In alkalosis, hydrogen ions shift out of the cells, and potassium moves into the cells, leading to hypokalemia.
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