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

Ciprofloxacin is an antibiotic used to treat different types of bacterial infections, including urinary tract infections. Drinking plenty of fluids can help flush out bacteria from the urinary tract and prevent dehydration. Taking an antacid can reduce the absorption of ciprofloxacin and make it less effective.

Monitoring heart rate is not necessary unless the client has a history of cardiac problems or is taking other medications that affect the heart . Taking a laxative can cause diarrhea, which can worsen dehydration and electrolyte imbalance.

A. Position the mouthpiece 2.5 cm (1 in) from the mouth. B. Exhale slowly through pursed lips. C. Hold breaths about 3 to 5 seconds before exhaling. D. Place hands on the upper abdomen during inhalation.

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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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 chronic urinary tract infections. The client has a prescription for ciprofloxacin 250 mg PO twice daily. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

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