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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A hacking cough, especially at night or when lying down, is a common manifestation of left-sided heart failure, as fluid accumulates in the lungs and causes pulmonary congestion and dyspnea. Neck-vein distention and ankle edema are more indicative of right-sided heart failure, as fluid backs up into the systemic circulation and causes peripheral edema and jugular venous pressure elevation. Anorexia may occur in either type of heart failure, but it is not specific to left-sided heart failure.
Correct Answer is D
Explanation
The nurse should plan to confirm the correct position of the line by obtaining a blood sample, as this is one of the methods to verify placement and patency of a central venous catheter. The nurse should also instruct the client to perform a Valsalva maneuver (bearing down) as the catheter is inserted, place the head of the client's bed higher than 30 degrees, and cleanse the site with an antiseptic solution such as chlorhexidine.
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