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 D
Explanation
A. Dependent edema may be present in pericarditis but is not typically the priority finding unless it indicates worsening heart failure.
B. Pericardial friction rub is a classic finding in pericarditis but is not the priority unless it indicates cardiac tamponade, which is a medical emergency.
C. Paradoxical pulse may occur in pericarditis but is not necessarily the priority finding unless it is severe and indicative of cardiac tamponade.
D. Substernal chest pain is the priority finding in pericarditis as it indicates inflammation of the pericardium, which can lead to complications such as myocardial infarction or cardiac
tamponade. Prompt intervention is necessary to alleviate pain and prevent complications.
Correct Answer is C
Explanation
A. The child develops a dry, hacking cough: This suggests ineffective clearance of secretions and may indicate a need for further intervention.
B. The child has increased nasal secretions: Nasal secretions are not directly related to the effectiveness of high-frequency chest compressions in clearing pulmonary secretions.
C. The child has increased sputum production: Increased sputum production indicates that the
treatment is effectively mobilizing and clearing mucus from the airways, which is beneficial for a child with cystic fibrosis.
D. The child develops diminished breath sounds: Diminished breath sounds could indicate a complication such as atelectasis or pneumothorax and would not be an expected finding with effective high-frequency chest compressions.
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