HESI COMPREHENSION EXAM 1
A nurse is assigned to care for a client with chronic renal failure who is undergoing hemodialysis through an internal ... [Show More] arteriovenous (AV) fistula in the right arm. Which of the following interventions should the nurse implement in caring for the client? Select all that apply.
Assessing the radial pulse in the right extremity Correct
Using the left arm to take blood pressure readings Correct
Drawing predialysis blood specimens from the left arm Correct
Assessing the area over the AV fistula for a bruit and thrill each shift Correct
Placing a pressure dressing over the site after each dialysis treatment
Administering intravenous (IV) fluids through the venous site of the AV fistula as needed
Rationale: Several precautions must be observed to ensure the function of an internal AV fistula. The nurse assesses the fistula, and the distal portion of the extremity, for adequate circulation; checks for a bruit and a thrill by means of auscultation or palpation over the access site; monitors the radial pulse in the extremity; and avoids taking blood pressure readings or drawing blood from the arm with the AV fistula. Venipuncture is avoided in the extremity bearing the AV fistula. Blood is never drawn from the AV fistula, and the AV fistula is not used for the administration of IV fluids. The AV fistula site is not covered with a pressure dressing after dialysis.
Test-Taking Strategy: Think of the AV fistula as the client’s lifeline. Recalling that the nurse must assess the fistula for patency and protect the site from injury will help you identify the appropriate interventions. Review care of the client with an AV fistula if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Critical thinking for collaborative care (6th ed., pp. 1623, 1624). St. Louis: Saunders.
Awarded 0.0 points out of 1.0 possible points.
A nurse is evaluating outcomes for a client with Guillain-Barré syndrome. Which of the following outcomes does the nurse recognize as optimal respiratory outcomes for the client? Select all that apply.
Normal deep tendon reflexes Incorrect
Improved skeletal muscle tone
Absence of paresthesias in the lower extremities Incorrect
Clear sounds in the lower lung fields bilaterally Correct
Po2 of 85% and Pco2 of 40 mm Hg Correct
Rationale: Satisfactory respiratory outcomes include clear breath sounds on auscultation, clear mentation, spontaneous breathing, normal vital capacity, and normal arterial blood gases. The ABG results listed here — a Po2 of 85% and a Pco2 of 40 mm Hg — are normal. The presence of normal deep tendon reflexes, improved skeletal muscle tone, and absence of paresthesias in the lower extremities reflect improvement in the symptoms associated with Guillain-Barré but are not specific to a respiratory outcome.
Test-Taking Strategy: Use the process of elimination and focus on the subject, optimal respiratory outcomes. Eliminate normal deep tendon reflexes, improved skeletal muscle tone, and absence of paresthesias in the lower extremities, because they are unrelated to the subject of the question. Review care of the client with Guillain-Barré syndrome and the expected respiratory outcomes of care if you had difficulty with this question. [Show Less]