The nurse is caring for a client with an AV fistula. Upon assessment the nurse notes that the extremity with the fistula is pale and cool. The nurse would initially:
1. Auscultate the fistula.
2. Notify the health care provider.
3. Check vital signs.
4. Document the finding.
Auscultate the fistula.
Rationale: Auscultating the fistula would allow the nurse to determine the presence of a bruit, which would indicate adequate blood flow through the fistula. The nurse would gather further assessment data prior to notifying the health care provider. Checking vital signs would not determine if the fistula was patent. Documenting the finding would not assist in determining the patency of the fistula.
You might also like to view...
Nurses are expected to know how to use the first genetic test. What is it?
A) The developmental assessment B) The family history C) The physical assessment D) The psychosocial assessment
A couple has delivered an infant with a serious genetic disorder. Which nursing diagnoses would likely apply to this family?
Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Altered Family Processes 2. Anticipatory Grieving 3. Anxiety 4. Ineffective Denial 5. Ineffective Management: Therapeutic Family Regimen
A nursing student is listening to a lecture on community assessment tools. The nursing instructor explains that PHNs have found that some of the best uses of the Geographic Information Systems (GIS) include which of the following?
A. To locate medical facilities B. To identify spatial data C. To display environmental risk factors and health risks D. To display demographic data E. To display socioeconomic data
The outcome that is the best evidence that a nursing student's time management plan is working is that the student
a. reports feeling happy at home. b. is popular with peers. c. achieves passing grades on tests and evaluations. d. demonstrates positive relationships with instructors.