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 B
Explanation
Choice A rationale
While the renin-angiotensin response can be affected in cirrhosis, it is not the primary mechanism contributing to edema and ascites. In cirrhosis, there can be a decrease in renal blood flow which can lead to activation of the renin-angiotensin system, but this is not the main cause of fluid accumulation.
Choice B rationale
Hypoalbuminemia, or low levels of albumin in the blood, is a common occurrence in cirrhosis. Albumin is a protein that helps maintain oncotic pressure, which keeps fluid in the blood vessels. When albumin levels are low, fluid can leak out of the blood vessels and accumulate in the abdomen (ascites) and in the tissues, causing edema.
Choice C rationale
Hyperaldosteronism can occur in cirrhosis and can contribute to fluid retention. However, it is not the primary mechanism leading to edema and ascites. Aldosterone promotes sodium and water reabsorption in the kidneys, which can contribute to fluid retention, but this is usually a secondary response to other changes in the body.
Choice D rationale
Decreased portacaval pressure with greater collateral circulation is not the primary mechanism contributing to edema and ascites in cirrhosis. While portal hypertension is a common complication of cirrhosis, it is not directly responsible for the development of edema and ascites.
Correct Answer is A
Explanation
Choice A rationale
A lumbar puncture is a key diagnostic procedure for suspected bacterial meningitis. It allows for the collection of cerebrospinal fluid, which can be analyzed for signs of bacterial infection.
Choice B rationale
Skull radiography is not typically used to diagnose bacterial meningitis. While it can help identify abnormalities in the structure of the skull or brain, it cannot detect the presence of bacteria.
Choice C rationale
While an MRI can provide detailed images of the brain and surrounding tissues, it is not the primary tool for diagnosing bacterial meningitis. It may be used in conjunction with other tests, but a lumbar puncture is more definitive.
Choice D rationale
A CT scan can be used to detect abnormalities in the brain, such as swelling or inflammation, which could be indicative of meningitis. However, it cannot definitively diagnose bacterial meningitis.
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