Which intervention does the nurse utilize post-operatively to assess the patency of the arteriovenous fistula?
Assess the fistula with a large bore needle
Auscultate the fistula site for a bruit.
Measure the blood pressure in the affected arm
Assess the rate and quality of the radial pulse on the affected arm
The Correct Answer is B
A. Assess the fistula with a large bore needle: Large bore needles are used during dialysis sessions, not for routine assessment. Inappropriate needling can damage the fistula.
B. Auscultate the fistula site for a bruit: A functional AV fistula should have a palpable thrill (vibration) and an audible bruit (whooshing sound) when auscultated with a stethoscope. These findings confirm adequate blood flow and patency.
C. Measure the blood pressure in the affected arm: Blood pressure measurements should never be taken on the fistula arm to prevent compression and potential fistula failure.
D. Assess the rate and quality of the radial pulse on the affected arm: The radial pulse does not accurately assess AV fistula patency; the focus should be on the thrill and bruit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. ST depression: ST depression is associated with hypokalemia or ischemia.
B. Tall peaked T waves: Hyperkalemia (K+ > 5.0 mEq/L) causes tall, peaked T waves due to abnormal repolarization. Severe hyperkalemia (>6.5 mEq/L) can lead to cardiac arrest.
C. Prolonged ST segment: Not a characteristic of hyperkalemia.
D. Prominent U wave: A U wave is seen in hypokalemia, not hyperkalemia.
Correct Answer is A
Explanation
A. Confusion: Respiratory acidosis (low pH + high PaCO2) leads to decreased oxygenation of brain tissues, causing confusion, drowsiness, and lethargy.
B. Kussmaul's Respirations: Seen in metabolic acidosis, not respiratory acidosis.
C. Seizures: Seizures are more common with alkalosis (high pH) due to neuronal excitability.
D. Paresthesia in the Extremities: More common in respiratory alkalosis due to calcium shifts.
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