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 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.

A. Morse Fall Risk scale B. Braden scale C. Pain assessment D. Neurovascular assessment

Correct Answer is D

Explanation

A) The Morse Fall Risk scale assesses the risk of falls in hospitalized patients but is not the priority for a postoperative client with an ORIF.
B) The Braden scale assesses the risk of pressure ulcers and is not the priority for a postoperative client with an ORIF.
C) Pain assessment is important but may not be the priority compared to assessing neurovascular status, especially immediately postoperatively.
D) The neurovascular assessment, including circulation, sensation, and movement, is crucial for early detection of complications such as compartment syndrome or impaired blood flow.

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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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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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