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 D

Explanation

A. Covering electrical outlets with tape may not be sufficient for safety and could pose a fire hazard. Safety covers designed for outlets are recommended.
B. Keeping the client's bedroom dark at night may increase confusion and disorientation. Soft lighting or nightlights are preferable.
C. While a calendar may be helpful, placing it in the client's bedroom may not be as beneficial as placing it in a common area where the client spends time during the day.Furthermore, amonthly calendar can be too complex for clients with Alzheimer’s disease, especially in the later stages. Simpler tools like a daily schedule or a weekly calendar are more effective.
D. A large-face clock can help the client orient to time and reduce confusion regarding the time of day.

A. Distended jugular veins B. Pitting, dependent edema C. Decreased blood pressure D. Increased blood pressure

Correct Answer is C

Explanation

A) Distended jugular veins are associated with fluid overload, not dehydration.

B) Pitting, dependent edema is also associated with fluid overload, not dehydration.

C) Decreased blood pressure is a common sign of dehydration due to decreased blood volume.
D) Increased blood pressure is not typically associated with dehydration and may suggest other conditions such as hypertension or fluid overload.

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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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