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
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Correct Answer is D
Explanation
The client is experiencing signs of an acute hemolytic transfusion reaction, which is a life-threatening emergency. The nurse should stop the infusion immediately and disconnect the blood tubing from the IV catheter to prevent further exposure to the incompatible blood.
Correct Answer is D
Explanation
A flat lesion with irregular borders is one of the signs of melanoma, a type of skin cancer that arises from melanocytes, the cells that produce pigment. Other signs of melanoma include asymmetry, color variation, diameter greater than 6 mm, and evolution or change over time. The other options are more characteristic of other types of skin cancer or benign lesions.
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