While caring for a client with an arteriovenous (AV) fistula in the left forearm, the practical nurse (PN) observed a palpable buzzing sensation over the fistula. Which action should the PN take?

Loosen the fistula dressing.

Document that the fistula is intact.

Apply gentle pressure over the site.

Report the presence of a bounding pulse.

Answer and Explanation

The Correct Answer is B

A. Loosen the fistula dressing: Not indicated unless the dressing is too tight, which is not mentioned.
B. Document that the fistula is intact: A palpable thrill indicates patency; no intervention needed.
C. Apply gentle pressure over the site: Could obstruct blood flow and damage the fistula.
D. Report the presence of a bounding pulse: A thrill is expected and normal; not a sign of complication.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A. The parent's version of the injury is different from the child's version: Inconsistent histories are a red flag for abuse and require further investigation.
B. The child has several abrasions on the chest and legs: Abrasions alone can occur with falls; they are not specific to abuse without suspicious patterns or locations.
C. The child looks at the floor when answering the nurse's questions: Avoidance may be due to shyness or fear but is not conclusive for abuse.
D. The parent refuses to answer questions about family history: While uncooperative behavior may be concerning, it is less direct than inconsistent injury accounts.

A. Recommend using guided imagery to relax. B. Reassure the client that it is still early. C. Inspect the room's environmental aspects. D. Shut the client's room door securely.

Correct Answer is C

Explanation

A. Recommend using guided imagery to relax:
May help, but before suggesting relaxation techniques, it’s important to assess for environmental factors interfering with sleep.

B. Reassure the client that it is still early:
This dismisses the client’s concern and does not address the cause of insomnia.

C. Inspect the room's environmental aspects:
First priority is to assess for environmental disturbances (noise, light, temperature) that may affect sleep and can be corrected immediately.

D. Shut the client's room door securely:
May reduce noise but is a single intervention without a full assessment of environmental causes.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

While caring for a client with an arteriovenous (AV) fistula in the left forearm, the practical nurse (PN) observed a palpable buzzing sensation over the fistula. Which action should the PN take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The parent of an school-aged child tells the practical nurse (PN) that the child fell out of a tree and hurt the child's arm and shoulder. Which assessment finding should the PN note as the most significant indicator of possible child abuse?

Correct Answer is A

Explanation

At 2100, an older adult client turns on the call light and reports to the practical nurse (PN) concerns of difficulty falling asleep. Which priority action should the PN implement?

Correct Answer is C

Explanation

While changing the dressing of a client's abdominal incision, the practical nurse (PN) observes a large amount of purulent drainage on the dressing. Which data should the PN collect first?

The practical nurse (PN) is administering otic drops to an adult who has a ruptured eardrum. Which action should the PN implement?

The home health practical nurse (PN) suspects elder abuse after observing fresh lacerations on the arms and leg of an older male client who lives with his daughter. Which action is most important for the PN to take?

The practical nurse (PN) caring for a toddler is preparing to conduct a routine focused assessment. Which action should the PN take to promote an environment of family-centered care?

During an interview, an older adult client answers some questions inappropriately. The practical nurse (PN) observes there is a hearing aid in one ear. Which intervention is most helpful in assisting the client to hear the PN's question?

The practical nurse (PN) is caring for a client whose urine drug screen is positive for cocaine. Which of the following behaviors is this client likely to exhibit during cocaine withdrawal?

An older adult resident calls the practical nurse (PN) to the room in a long-term care facility. The resident reports an episode of vomiting and shows the PN the contents of the emesis basin. The PN observes the emesis. Which action is most important for the PN to take?