Nokea
A nurse is caring for a client 2 days after surgical creation of an arteriovenous fistula in the forearm. Which finding should the nurse report immediately to the health care provider?
- A. 2+ pitting edema of the extremity with the arteriovenous fistula
- B. Loud swooshing sound auscultated over the arteriovenous fistula
- C. Pale skin of the hand of the arm with the arteriovenous fistula
- D. Surgical site pain reported by the client as 3 on a scale of 0-10 during hand exercises
Correct Answer: C
Rationale: Pale skin in the hand (C) suggests vascular compromise, risking fistula failure or ischemia, requiring immediate reporting. Edema (A) is common, a swooshing sound (B) indicates patency, and mild pain (D) is expected.
You may also like to solve these questions
An adult is admitted with a head injury following an accident. He has a severe headache and asks the nurse why he cannot have something for pain. The nurse understands that the client should not receive a narcotic analgesic for which reason?
- A. Narcotic analgesics cause mydriasis, which will raise intracranial pressure.
- B. Narcotic analgesics are not effective for pain caused by brain trauma.
- C. Narcotic analgesics cause vomiting, which would mask a sign of increased intracranial pressure.
- D. Narcotic analgesics may depress respirations, which would cause acidosis and further brain damage.
Correct Answer: D
Rationale: Narcotics depress respirations, risking CO2 retention, acidosis, and increased intracranial pressure in head injury clients. Mydriasis, ineffectiveness, or vomiting are less critical concerns.
The emergency room nurse admits a child who experienced a seizure at school. The parent comments that this is the first occurrence and denies any family history of epilepsy. What is the best response by the nurse?
- A. Do not worry. Epilepsy can be treated with medications.
- B. The seizure may or may not mean your child has epilepsy.
- C. Since this was the first convulsion, it may not happen again.
- D. Long term treatment will prevent future seizures.
Correct Answer: B
Rationale: The seizure may or may not mean your child has epilepsy. A single seizure has multiple potential causes, not necessarily epilepsy.
A mother noticed a large abdominal mass when helping her 3-year-old child bathe. The child is taken to the physician and admitted to the hospital after an intravenous pyelogram (IVP) confirms the diagnosis of Wilms' tumor. Which nursing action is essential to include in the nursing care plan?
- A. Strain all urine and save for analysis.
- B. Avoid palpating the abdomen.
- C. Prepare the child for permanent dialysis.
- D. Help the family understand the poor prognosis.
Correct Answer: B
Rationale: Avoiding abdominal palpation prevents potential tumor rupture or metastasis in Wilms' tumor, a critical precaution. Urine straining, dialysis, or poor prognosis are inappropriate.
A client is being discharged after receiving an implantable cardioverter defibrillator. Which statement by the client indicates that teaching has been effective?
- A. I’m not worried about the device firing now because I know it won’t hurt.
- B. I will let my daughter fix my hair until my health care provider says I can do it.
- C. I will look into public transportation because I won’t be able to drive again.
- D. I will notify my travel agent that I can no longer travel by plane.
Correct Answer: B
Rationale: Avoiding hair-fixing (B) prevents arm movement that could dislodge leads, showing effective teaching. Device firing (A) can be uncomfortable, driving (C) is restricted temporarily, and air travel (D) is generally safe with precautions.
An adult is admitted with meningitis. During the acute phase of the illness, which measure should the nurse include in the nursing care plan to reduce the chance of seizures?
- A. Play the client's favorite music.
- B. Stimulate the client every two hours.
- C. Keep a padded tongue blade at the bedside.
- D. Darken the client's room.
Correct Answer: D
Rationale: Darkening the room minimizes sensory stimulation, reducing seizure risk in meningitis, where neurological irritability is common.