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.

Nursing Test Bank

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

Explanation

A) The client’s blood glucose in this scenario is within the normal range.
B) The bowel sounds in this scenario are present in all the 4 quadrants which is normal.
C) The client's blood pressure is elevated at 164/80 mm Hg. Hypertension can exacerbate cardiac ischemia and increase the risk of complications. Therefore, monitoring and potential management of blood pressure are warranted.
D) The client's blood pressure is elevated at 164/80 mm Hg. Hypertension can exacerbate cardiac ischemia and increase the risk of complications. Therefore, monitoring and potential management of blood pressure are warranted.
E) The client's blood pressure is elevated at 164/80 mm Hg. Hypertension can exacerbate cardiac ischemia and increase the risk of complications. Therefore, monitoring and potential management of blood pressure are warranted.
F) The lungs are clear on auscultation of all the lobes which is normal.

G) The client's blood pressure is elevated at 164/80 mm Hg. Hypertension can exacerbate cardiac ischemia and increase the risk of complications. Therefore, monitoring and potential management of blood pressure are warranted.

A. Increase the client's ventilator flow rate. B. Empty water from the client's ventilator tubing. C. Evaluate the client for a cuff leak. D. Suction the client's airway.

Correct Answer is C

Explanation

A) Increasing the ventilator flow rate may not address the cause of the low-pressure alarm and could potentially worsen the situation.
B) Emptying water from the ventilator tubing is not typically necessary when the low-pressure alarm sounds.
C) Evaluating the client for a cuff leak is essential because a leak in the endotracheal tube cuff can cause the low-pressure alarm to sound.
D) Suctioning the client's airway is not indicated unless there are signs of airway obstruction or secretions.

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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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Explanation

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Correct Answer is C

Explanation

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