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 B

Explanation

A monthly calendar can help the client with Alzheimer's disease to orient to time and date and reduce confusion and anxiety. The nurse should encourage the family to use simple and clear reminders and cues to assist the client with daily activities and routines.

Covering electrical outlets with tape is not necessary and may pose a fire hazard. Keeping the client's bedroom dark at night may increase the risk of falls and injuries. A large-face clock may be helpful, but not as much as a calendar.

A. Wound tissue firm to palpation B. Dry brown eschar C. Light yellow exudate D. Dark red granulation tissue

Correct Answer is D

Explanation

A pressure ulcer is a localized injury to the skin and underlying tissue caused by prolonged pressure, shear, friction, or moisture.

Granulation tissue is new connective tissue and blood vessels that form on the surface of a wound during healing . It is usually dark red or pink in color and moist in appearance . Wound tissue that is firm to palpation may indicate edema, inflammation, or infection . Dry brown eschar is dead tissue that covers the wound and prevents healing . Light yellow exudate is a sign of wound infection or necrosis .

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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 teaching the family of a client who has Alzheimer's disease about caring for the client at home. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

A nurse is assessing a client who has a pressure ulcer. Which of the following findings should the nurse expect as an indication the wound is healing?

Correct Answer is D

Explanation

A nurse in an emergency department is preparing a client for emergency surgery. The client's blood alcohol level is 180 mg/dL. Which of the following actions is the nurse's priority?

A nurse is assessing a client who has acute kidney failure. Which of the following findings should the nurse report to the provider?

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A nurse is caring for a client who is experiencing an acute asthma attack. Which of the following should the nurse identify as a contributing factor to the client's manifestations?

A nurse is teaching about measures to prevent recurring urinary tract infections with a female client. Which of the following information should the nurse include in the teaching? (Select all that apply.)

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