A nurse is caring for a client who has a new arteriovenous (AV) graft in his left forearm. Which of the following techniques should the nurse use to assess the patency of this graft?
Auscultate the site for a bruit.
Measure the client's blood pressure to ensure it is higher in the left arm than the right.
Auscultate the antecubital fossa using a Doppler.
Check the brachial and radial pulses of the left arm simultaneously.
The Correct Answer is A
A. Auscultating for a bruit at the site of an AV graft is the most appropriate method to assess its patency. A bruit is a sound made by turbulent blood flow, indicating that the graft is functioning.
B. Measuring blood pressure in both arms does not specifically assess the patency of the graft and could potentially harm the graft if measured in the affected arm.
C. Auscultating the antecubital fossa using a Doppler is not a standard practice for assessing AV graft patency; instead, a stethoscope is used directly over the graft site.
D. Checking the brachial and radial pulses does not assess the graft directly. Although pulse presence is important, it does not provide information about the graft’s patency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Desmopressin is a synthetic analog of antidiuretic hormone (ADH) and is used to reduce urine output in conditions like diabetes insipidus. Monitoring urine output is the primary way to assess the effectiveness of this medication. A decrease in urine volume indicates the medication is working effectively.
B. Pupillary response is not relevant in assessing the effectiveness of desmopressin.
C. Temperature monitoring is important in general patient care but does not directly relate to the effectiveness of desmopressin.
D. Apical heart rate is important to monitor in many scenarios but is not a direct indicator of desmopressin's effectiveness.
Correct Answer is A
Explanation
A. Slow, steady bubbling in the suction control chamber indicates that the system is functioning correctly. The nurse should continue to monitor the client's respiratory status and the drainage system.
B. Clamping the chest tube is not indicated unless instructed by the healthcare provider, as it could lead to a dangerous buildup of pressure in the pleural space.
C. Checking the suction control outlet on the wall is not necessary if the suction control chamber is already bubbling steadily.
D. Checking the tubing connections for leaks is unnecessary if the bubbling is slow and steady, as this indicates the system is working properly.
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