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.
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Related Questions
Correct Answer is ["B","E","F"]
Explanation
A. The vital signs are stable and within normal limits. The slight drop in blood pressure post-dialysis is expected and not immediately concerning.
B. The client's weight decreased from 90 kg (198 lb) to 86.4 kg (190 lb) after dialysis. While weight loss is expected due to fluid removal during dialysis, this significant decrease (3.6 kg or approximately 8 lb) may need closer monitoring to ensure the client is not becoming dehydrated or losing more fluid than is safe.
C. The blood glucose levels are within an acceptable range for a client with type 2 diabetes mellitus. The slight decrease from 134 mg/dL to 75 mg/dL is not unusual given the time between measurements and the client's food intake.
D. The presence of a bruit and thrill at the AV fistula site indicates that it is functioning correctly, which is an expected finding.
E. The presence of crackles in the left lower lobe and an unproductive cough on the morning of Day 2 is concerning. These symptoms could indicate fluid overload or early signs of pulmonary edema, which require further evaluation and possible intervention.
F. The AV fistula site is noted to be ecchymotic and warm, with a bruit and thrill still present. While a bruit and thrill are expected findings, the ecchymosis and warmth could indicate a developing infection or trauma at the site, which necessitates further follow-up to prevent complications.
Correct Answer is D
Explanation
A. Levofloxacin is an antibiotic used to treat bacterial infections, not hypothyroidism.
B. Radioactive iodine is used to treat hyperthyroidism by reducing thyroid hormone production, not hypothyroidism.
C. Sumatriptan is a medication used to treat migraines, not hypothyroidism.
D. Levothyroxine is the standard treatment for hypothyroidism. It is a synthetic form of the thyroid hormone thyroxine (T4) and helps to normalize thyroid function by supplementing the hormone that the thyroid gland is not producing adequately
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