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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Limiting walking episodes may reduce discomfort but does not address the underlying issue or potential complications.

B. While leg cramps can be common during pregnancy, calf pain could also indicate a more serious condition, such as deep vein thrombosis (DVT), and should not be dismissed as normal without further investigation.

C. Gathering further assessment data is crucial to determine the cause of the calf pain, as it may indicate DVT, a potentially life-threatening condition. The nurse should assess for other symptoms like swelling, redness, or warmth in the leg.

D. Instructing the client to elevate the legs may be appropriate for general discomfort, but without proper assessment, it may not be the correct intervention if DVT is present.

A. The impairment to blood flow if the stockings are too tight B. The removal of the stocking only once daily for 30 minutes. C. Skin hygiene and assessment to be done each time the stockings are removed D. The need to wear the stocking when both in and out of bed E. The measuring of the length and circumference of the leg to ensure proper fit.

Correct Answer is ["A","C","D","E"]

Explanation

A. The nurse should inform the client that if the stockings are too tight, they may impair blood flow rather than prevent it, which could increase the risk of complications such as pressure sores or circulatory issues.

B. While the stockings should be removed periodically, removing them only once daily for 30 minutes may not be sufficient for skin inspection and care. Best practice usually involves removing them more frequently, such as every 8 hours, to check for skin integrity.

C. Proper skin hygiene and regular assessment should be performed each time the stockings are removed to ensure there is no irritation, breakdown, or circulatory impairment.

D. Antiembolism stockings are designed to be worn both in and out of bed to maintain consistent pressure on the legs and reduce the risk of deep vein thrombosis (DVT).

E. Proper measuring of the leg is crucial to ensure that the stockings fit correctly, providing the necessary compression without being too tight or too loose.

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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?

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Naxlex Comprehensive Predictor Exams

A prenatal client is experiencing calf pain when she walks. Which action is appropriate for the nurse to implement?

Correct Answer is C

Explanation

What information would the nurse include when educating a postsurgical client on the proper use of antiembolism stockings? (Select all that apply)

Correct Answer is ["A","C","D","E"]

Explanation

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