A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft?

Palpable thrill

Absence of a bruit

Normotensive blood pressure

Dilated appearance of the graft

Answer and Explanation

The Correct Answer is A

A. A palpable thrill over the graft site indicates adequate blood flow through the graft.

B.   The presence of a bruit (a humming sound) over the graft site is expected and indicates blood flow.
C.   Normotensive blood pressure is not specifically indicative of the circulation of the graft.
D.   A dilated appearance of the graft may indicate an issue with the graft, such as an aneurysm, rather than adequate circulation.

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Correct Answer is B

Explanation

A) Limiting time for visitors is necessary in this case. However, the time should be limited to 1 hour in 24 hours and not 2 hours.
B) Instructing visitors to remain 6 feet from the client is crucial for their safety to minimize radiation exposure. Brachytherapy involves the use of a radioactive source placed close to or inside the tumor, and while the patient is emitting radiation, safety precautions must be taken to protect others from exposure. Safety measures such as maintaining a safe distance help ensure that the radiation exposure to others is As Low As Reasonably Achievable (ALARA), a principle that aims to minimize exposure while achieving the necessary therapeutic effect.
C) Discarding the radioactive device in the client's trash can is incorrect as it poses a risk of exposure to others.
D) Keeping soiled bed linens in the client's room is incorrect as they may be contaminated with radiation and should be handled according to radiation safety protocols.

A. Pad the upper two side rails of the client's bed. B. Maintain peripheral IV access. C. Teach assistive personnel how to apply restraints. D. Keep a padded tongue blade at the client's bedside. E. Keep a padded tongue blade at the client's bedside.

Correct Answer is A

Explanation

A) Padding the upper two side rails of the client's bed helps prevent injury during a seizure by reducing the risk of head trauma.
B) Maintaining peripheral IV access may not directly address the client's safety during a seizure.
C) Teaching assistive personnel to apply restraints is not appropriate for managing seizures and may not be indicated unless other safety measures have failed.
D) Keeping a padded tongue blade at the client's bedside is not necessary and may not be safe if the client experiences a seizure.

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A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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