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.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale
Huff coughing is a method that forces mucus up your throat by breathing it in, holding it, and actively exhaling. It’s different from a typical cough and more effective in clearing mucus from the lungs. Pursed-lip breathing, which the patient is doing, is not part of the huff coughing technique.
Choice B rationale
Taking several shallow breaths before the next exhalation is not part of the huff coughing technique. The technique involves taking a slow and deep breath until your lungs are about 75% full, holding your breath for two to three seconds, and then exhaling slowly but strongly.
Choice C rationale
Instructing the patient to inhale deeply and then quickly and forcefully exhale 2 to 3 times is the correct method for huff coughing. This technique helps to move mucus from the smaller airways to the larger ones, making it easier to cough up and out.
Choice D rationale
Positioning the patient in the semi-Fowler’s position and applying oxygen is not part of the huff coughing technique. While oxygen therapy can be beneficial for patients with COPD, it does not directly aid in the huff coughing technique.
Correct Answer is A
Explanation
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.
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