A nurse is assessing a client who has an arteriovenous (AV) graft in the right forearm for hemodialysis access. The nurse auscultates a bruit over the graft area. Which intervention should the nurse implement?
Document the findings.
Elevate the extremity.
Apply gentle pressure.
Assess the client’s temperature.
The Correct Answer is A
Choice A rationale
Auscultating a bruit over the graft area of a client who has an arteriovenous (AV) graft in the right forearm for hemodialysis access is a normal finding. A bruit is a vibration felt over the graft that indicates blood flow. Therefore, the nurse should document the findings as it indicates the graft is patent and functioning properly.
Choice B rationale
Elevating the extremity is not necessary in this case. The presence of a bruit indicates that the graft is functioning properly.
Choice C rationale
Applying gentle pressure is not the appropriate intervention in this case. The presence of a bruit is a positive sign indicating the graft is functioning properly.
Choice D rationale
Assessing the client’s temperature is not directly related to the presence of a bruit over the graft area. The temperature would not provide information about the patency or function of the AV graft.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
As with, a lumbar puncture is the primary diagnostic procedure for suspected bacterial meningitis. The other choices, while useful for detecting other conditions, are not as definitive for diagnosing bacterial meningitis.
Choice B rationale
As mentioned in the rationale for, Choice B, skull radiography is not typically used to diagnose bacterial meningitis.
Choice C rationale
As mentioned in the rationale for, Choice C, an MRI can provide detailed images of the brain and surrounding tissues, but it is not the primary tool for diagnosing bacterial meningitis.
Choice D rationale
As mentioned in the rationale for, Choice D, a CT scan can detect abnormalities in the brain, but it cannot definitively diagnose bacterial meningitis.
Correct Answer is ["A","D","E"]
Explanation
Furosemide is a loop diuretic used to treat fluid retention and high blood pressure by increasing the amount of urine the body makes. Therefore, assessing urinary output is crucial to determine the patient’s response to treatment. Lung sounds and oxygen saturation should also be assessed as furosemide is often used to treat edema caused by heart failure. Improved lung sounds and oxygen saturation can indicate a reduction in fluid buildup in the lungs.
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