The practical nurse (PN) is preparing to transfer an older client from the bed to a wheelchair. Based on which finding should the PN request assistance when moving this client?

A. Radial pulse distal to AVF is absent and ulnar pulse is present: The presence of a palpable ulnar pulse suggests some distal perfusion remains. While changes in distal pulses should be monitored, this finding alone may not indicate an acute complication requiring immediate reporting.

B. Bruising at the AVF site is purple and green in color: Minor bruising can occur after fistula creation and is typically expected during healing. Unless accompanied by swelling, pain, or signs of hematoma expansion, it does not necessitate immediate reporting.

C. Descriptions of numbness and tingling in fingers distal to the AVF: Numbness and tingling may indicate ischemia or compromised circulation distal to the fistula, a serious complication that requires prompt evaluation by the healthcare provider to prevent tissue damage.

D. A loud and consistent bruit is auscultated at the AVF site: A palpable thrill and auscultated bruit are normal findings indicating proper fistula function. Continuous monitoring is necessary, but this finding does not require reporting if consistent and expected.

A. Measure and record the client's intake and output: Monitoring intake and output is useful for assessing hydration status, especially during chemotherapy, but it does not address the potential infectious process indicated by the productive cough.

B. Notify the charge nurse of the assessment findings: Chemotherapy suppresses bone marrow function, placing the client at risk for infection even in the absence of fever. A productive cough with yellow-tinged sputum suggests possible infection, requiring prompt reporting so diagnostic tests and interventions can be initiated quickly.

C. Plan to re-assess the client's temperature in two hours: Waiting to reassess delays recognition of a potentially serious infection. Immunocompromised clients may not develop a fever despite significant infection, making early reporting and evaluation essential.

D. Provide oral hygiene on a regular, frequent schedule: Regular oral care is important in reducing infection risk but is not the immediate priority. The PN must first ensure that potential respiratory infection symptoms are communicated to initiate timely evaluation.