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 C
Explanation
Sinus bradycardia is a type of cardiac arrhythmia characterized by a heart rate lower than 60 beats per minute in adults, or below the normal range for age in children. It can be diagnosed by an electrocardiogram (ECG) that shows regular P waves with constant morphology preceding every QRS complex, and positive in lead II.
Correct Answer is C
Explanation
An incentive spirometer is a device that helps improve lung function by encouraging deep breathing and preventing atelectasis (collapse of alveoli) after surgery or prolonged bed rest. The client should position the mouthpiece firmly in their mouth, inhale deeply and slowly through the mouthpiece until the indicator reaches the desired level, hold their breath for 3 to 5 seconds, and then exhale normally through their nose or mouth.
Exhaling slowly through pursed lips or placing hands on the upper abdomen are techniques that can help with dyspnea (shortness of breath), but are not part of using an incentive spirometer. Positioning the mouthpiece 2.5 cm.
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