Nokea
The nurse creates a care plan for a client receiving hemodialysis through an arteriovenous (AV) fistula in the right arm. The nurse includes which interventions in the plan to protect the AV fistula from injury? Select all that apply.
- A. Assess pulses and circulation proximal to the fistula.
- B. Palpate for thrills and auscultate for a bruit every 4 hours.
- C. Check for bleeding and infection at hemodialysis needle insertion sites.
- D. Avoid taking blood pressure or performing venipunctures in the extremity.
- E. Instruct the client not to carry heavy objects or anything that compresses the extremity.
- F. Instruct the client not to sleep in a position that places her or his body weight on top of the extremity.
Correct Answer: B,C,D,E,F
Rationale: An AV fistula is an internal anastomosis of an artery to a vein and is used as an access for hemodialysis. The nurse should implement the following to protect the fistula: palpate for thrills and auscultate for a bruit every 4 hours, check for bleeding and infection at hemodialysis needle insertion sites, avoid taking blood pressures or performing venipunctures in the extremity, instruct the client not to carry heavy objects or anything that compresses the extremity, instruct the client not to sleep in a position that places the body weight on top of the extremity, and the nurse should assess pulses and circulation distal to the fistula.
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The nurse is reviewing the antenatal history of several clients in early labor. The nurse recognizes which factor documented in the history as having the potential for causing neonatal sepsis after delivery? Select all that apply.
- A. Of Asian heritage
- B. Two previous miscarriages
- C. Prenatal care began during the 3rd trimester
- D. History of substance abuse during pregnancy
- E. Dietary assessment identified poor eating habits
- F. Spontaneous rupture of membranes 24 hours ago
Correct Answer: C,D,E,F
Rationale: Risk factors for neonatal sepsis can arise from maternal, intrapartal, or neonatal conditions. Maternal risk factors before delivery include a history of substance abuse during pregnancy, low socioeconomic status, and poor prenatal care and nutrition. Premature rupture of the membranes or prolonged rupture of membranes greater than 18 hours before birth is also a risk factor for neonatal acquisition of infection. There is no research to associate heritage or previous miscarriages to the development of neonatal sepsis.
A client with a colostomy reports gas buildup in the colostomy bag. The nurse instructs the client that consuming which food items would help prevent this problem? Select all that apply.
- A. Yogurt
- B. Broccoli
- C. Cabbage
- D. Crackers
- E. Cauliflower
- F. Toasted bread
Correct Answer: A,D,F
Rationale: Consumption of yogurt, crackers, and toasted bread can help prevent gas. Gas-forming foods include broccoli, mushrooms, cauliflower, onions, peas, and cabbage. These foods should be avoided by the client with a colostomy until tolerance to them is determined.
The nurse notes an isolated premature ventricular contraction (PVC) on the cardiac monitor of a client recovering from anesthesia. Which action should the nurse take?
- A. Prepare for defibrillation.
- B. Continue to monitor the rhythm.
- C. Prepare to administer lidocaine hydrochloride.
- D. Notify the primary health care provider immediately.
Correct Answer: B
Rationale: As an isolated occurrence, the PVC is not life-threatening. In this situation, the nurse should continue to monitor the client. Frequent PVCs, however, may be precursors of more life-threatening rhythms, such as ventricular tachycardia and ventricular fibrillation. If this occurs, the primary health care provider needs to be notified. Defibrillation is done to treat ventricular fibrillation. Lidocaine hydrochloride is not needed to treat isolated PVCs; it may be used to treat frequent PVCs in a client who is symptomatic and is experiencing decreased cardiac output.
The nurse, caring for a client with Buck's traction, is monitoring the client for complications of the traction. Which assessment finding indicates a complication of this form of traction?
- A. Weak pedal pulses
- B. Drainage at the pin sites
- C. Complaints of leg discomfort
- D. Toes demonstrating a brisk capillary refill
Correct Answer: A
Rationale: Buck's traction is skin traction. Weak pedal pulses are a sign of vascular compromise, which can be caused by pressure on the tissues of the leg by the elastic bandage or prefabricated boot used to secure this type of traction. Skeletal (not skin) traction uses pins. Discomfort is expected. Warm toes with brisk capillary refill is a normal finding.
The nurse is assessing a client who is being treated with a beta-adrenergic blocker. Which assessment findings would indicate that the client may be experiencing dose-related side effects of the medication? Select all that apply.
- A. Dizziness
- B. Bradycardia
- C. Chest pain
- D. Reflex tachycardia
- E. Sexual dysfunction
- F. Cardiac dysrhythmias
Correct Answer: A,B,E
Rationale: Beta-adrenergic blockers, commonly called beta blockers, are useful in treating cardiac dysrhythmias, mild hypertension, mild tachycardia, and angina pectoris. Side effects commonly associated with beta blockers are usually dose related and include dizziness (hypotensive effect), bradycardia, hypotension, and sexual dysfunction (impotence). Options 3, 4, and 6 are reasons for prescribing a beta blocker; however, these are general side effects of alpha-adrenergic blockers.