A nurse is planning care for a client who is postoperative following creation of an arteriovenous fistula in the left arm. Which of the following actions should the nurse include in the plan?
Auscultate the client's left arm for a bruit every 4 hours.
Compare blood pressure in both arms every 2 hours.
Instruct the client to keep the left arm in a dependent position.
Encourage the client to restrict movement of the left arm.
The Correct Answer is A
A.
A. Auscultating the client's left arm for a bruit helps assess the patency and function of the arteriovenous fistula. A bruit indicates normal blood flow through the fistula.
B. Comparing blood pressure in both arms every 2 hours is not specifically related to monitoring the arteriovenous fistula. Blood pressure comparison may be done periodically but is not as directly relevant to postoperative care of the fistula.
C. Instructing the client to keep the left arm in a dependent position may help with venous return but is not the primary action for monitoring the arteriovenous fistula's patency and function.
D. Encouraging the client to restrict movement of the left arm is not necessary unless there are specific instructions from the surgeon. Encouraging gentle movement and range of motion exercises may actually be beneficial for preventing stiffness and promoting healing.
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Related Questions
Correct Answer is C
Explanation
A: Tucking the chin while swallowing can actually help prevent aspiration in clients with dysphagia, as it narrows the tracheal opening and helps direct food away from the airway.
B: Sitting upright during meals is a recommended practice to reduce the risk of aspiration. It allows gravity to assist with the movement of food, reducing the likelihood of it entering the airway.
C: Pocketing food on one side of the mouth can be a sign of reduced sensation or motor control on that side, often a result of a stroke. This can lead to unnoticed accumulation of food which may then be aspirated.
D: A cough reflex is a protective mechanism against aspiration. If food enters the airway, the cough reflex should trigger, helping to expel the food from the airway and prevent aspiration.
Correct Answer is C
Explanation
A. Hydrogen peroxide is not recommended for cleaning surfaces contaminated with blood as it is not as effective as other agents and may not adequately disinfect surfaces.
B. Isopropyl alcohol can be effective for disinfecting surfaces contaminated with blood, but it is less effective against certain bloodborne pathogens like hepatitis B virus compared to chlorine bleach.
C. Chlorine bleach is an effective agent for cleaning surfaces contaminated with blood and is recommended by CDC guidelines for disinfecting against bloodborne pathogens.
D. Chlorhexidine is primarily used as a skin antiseptic and is not typically used for cleaning surfaces contaminated with blood.
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