A nurse is planning care for a client who has a newly implanted arteriovenous graft in the right arm. Which of the following actions should the nurse include in the plan of care?

Insert a saline lock into a site 10 cm (4 in) distal to the graft.

Instruct the client to avoid lifting the right arm for 72 hr.

Palpate the site for a thrill.

Check blood pressure in the right arm.

Answer and Explanation

The Correct Answer is C

Palpating the site for a thrill is an important action to assess the patency and function of an arteriovenous graft, which is a synthetic tube that connects an artery and a vein for hemodialysis access. A thrill is a vibration felt over the graft that indicates blood flow. The other options are incorrect because they could compromise or damage the graft.

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Correct Answer is C

Explanation

An ileostomy is a surgical opening in the abdomen that connects the end of the small intestine (ileum) to a pouch or bag on the outside of the body. The ileostomy bypasses the large intestine (colon) and rectum, which normally absorb water and form solid stools. Therefore, the client should expect their stools to be loose and watery. The client should empty their bag several times a day, not when it is full, to prevent leakage and skin irritation. The client should avoid laxatives, which can cause dehydration and electrolyte imbalance. The client should also avoid high-fiber foods, which can cause blockage or irritation of the ileostomy.

A. "Most clients feel better after taking the antibiotic." B. "Your provider wouldn't prescribe this medication if it weren't necessary." C. "I will tell your provider that you do not want to take this medication." D. "If you don't take this medication, you will feel worse."

Correct Answer is C

Explanation

B. This response educates the client about the importance of taking the prescribed medication and reinforces the authority and expertise of the provider. However, it does not respect the client's autonomy to make independent healthcare decisions

C.This response acknowledges that the client has reservations about the antibiotics and offers to communicate this to the healthcare provider for further intervention.

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A nurse is planning care for a client who has a newly implanted arteriovenous graft in the right arm. Which of the following actions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who has an ileostomy. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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