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 A

Explanation

Protamine sulfate is an antidote for heparin overdose and can reverse its anticoagulant effects. It should be available at the bedside in case of bleeding complications or heparin toxicity. The nurse should monitor the client's activated partial thromboplastin time (aPTT) and adjust the heparin infusion rate accordingly.

A. Administer proparacaine eyedrops into the affected eye. B. Instill 0.9% sodium chloride solution into the affected eye. C. Collect information about the irritant that caused the injury. D. Place a strip of pH paper onto the cul-de-sac of the affected eye.

Correct Answer is C

Explanation

The first action that the nurse should take is to collect information about the irritant that caused the injury, as this will help determine the appropriate treatment and duration of irrigation. Ocular irrigation is the process of flushing the eye with sterile fluid to remove foreign substances or chemicals.

Different types of chemicals may have different effects on the eye, such as acid burns, alkali burns, or organic solvents. Therefore, it is essential to identify the type and concentration of the chemical, as well as the time and duration of the exposure, before proceeding with the irrigation.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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