The nurse is caring for a client with end stage renal disease. What action should the nurse take to assess for patency in a fistula used for hemodialysis?

Correct Answer: C

Rationale: The correct answer is C) Palpate for a thrill over the fistula. This action is important because a thrill is a vibrating sensation that can be felt over a functioning fistula, indicating proper blood flow. Assessing for a thrill is a key nursing intervention to ensure the patency of the fistula and the success of hemodialysis treatments. This assessment technique allows the nurse to detect any potential issues with blood flow promptly. Option A) Observe for edema proximal to the site is incorrect because edema may not always be present even if there is an issue with the fistula. Option B) Irrigate with 5 mls of 0.9% Normal Saline is incorrect as it is not a standard practice to irrigate a fistula without a specific medical order. Option D) Check color and warmth in the extremity is also incorrect because while changes in color and warmth can indicate issues, they may not always be reliable indicators of fistula patency. In an educational context, it is crucial for nursing students to understand the importance of proper fistula assessment in clients with end-stage renal disease. By mastering this skill, students can ensure the safety and effectiveness of hemodialysis treatments for their patients, promoting positive outcomes and quality care.

Correct Answer: C

Rationale: Idiosyncratic response means it occurs because of an unknown reason. This response to something the body has been exposed to before is not unknown. Autoimmune disorders are ones in which the body attacks self-cells. This example is an outside antigen. Type I hypersensitivities are those that occur when the body, previously sensitized to a substance, is then exposed a second time and reacts. Immunossuppression occurs when the immune system is not working. Mr. Rowe's immune system responded to the antigen, so it is not suppressed.

Correct Answer: B

Rationale: Preventing injury by restraining the client, if necessary, is a nursing action of stage II, which extends from loss of consciousness to relaxation. Stage III extends from the loss of lid reflex to cessation of voluntary respirations. Operative procedures are performed during stage III of inhalation anesthesia. Promoting restoration of ventilation and vasomotor tone is a nursing action for stage IV in which an overdose has occurred. Respiratory arrest and vasomotor collapse result from medullary paralysis. Reduction of external stimuli is a nursing action for stage I, which extends from induction to loss of consciousness.

Correct Answer: C

Rationale: Vital signs may be altered if there is acute pain or complications related to bleeding or swelling, but it should not be assessed before checking the affected extremity. The extremity can be elevated if ordered by the physician. Assessment of the postoperative area is important to determine the presence of bleeding, swelling, or decreased circulation. Reinforcement of teaching on the use of the patient-controlled anesthesia (PCA) pump is important, but it is not the first action.

Correct Answer: C

Rationale: In the context of a client post-CABG surgery, the most important electrolyte to monitor is potassium (Option C). This is because potassium plays a crucial role in cardiac function, and imbalances can have serious consequences, including cardiac arrhythmias. Following cardiac surgery, there can be shifts in potassium levels due to various factors such as medications, fluid shifts, and stress on the body. Chloride (Option A) and bicarbonate (Option B) are important electrolytes as well, but they are not as directly linked to cardiac function as potassium. Monitoring chloride levels can be important in assessing acid-base balance, while bicarbonate levels are often monitored in conditions affecting acid-base status. Sodium (Option D) is also vital for overall health, but in the context of post-CABG care, potassium takes precedence due to its specific role in maintaining cardiac rhythm. Sodium levels are commonly monitored for fluid balance and nerve function. Educationally, understanding the significance of electrolyte monitoring post-cardiac surgery is crucial for nurses and healthcare providers to ensure optimal patient outcomes. Knowledge of how electrolyte imbalances can impact cardiac function and overall health is essential for providing safe and effective care to post-surgical patients.