A nurse is planning care for a client who is postoperative following insertion of an arteriovenous graft in their left forearm. Which of the following actions should the nurse include in the plan of care?
Check the pulse distal to the graft.
Splint the left forearm to prevent damage to the graft.
Collect blood specimens from the graft.
Keep the left forearm below the level of the heart.
The Correct Answer is A
A Checking the pulse distal (beyond) to the AV graft site is crucial to assess peripheral circulation. It helps determine if the graft is adequately perfusing blood to the distal extremity. Absence or weak pulse distal to the graft could indicate graft malfunction or complications such as thrombosis or inadequate blood flow.
B. Splinting the forearm may help immobilize the arm and reduce movement that could potentially disrupt the AV graft site. However, immobilization should be balanced with promoting mobility and preventing complications such as joint stiffness or pressure injuries.
C. Drawing blood from the AV graft could introduce infection risk or damage the graft site. It is standard practice to avoid using the AV graft for routine blood draws
D. Positioning the forearm below the level of the heart promotes venous return and reduces swelling or edema in the extremity. However, for an AV graft, maintaining the arm in a dependent position should be avoided to prevent excessive pressure on the graft site or compromising blood flow.
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Related Questions
Correct Answer is B
Explanation
B. When using a quad cane, the client should always maintain two points of support on the floor: the cane and either the affected (left) or unaffected (right) leg. This ensures stability and support while walking.
A When using a quad cane, the client should advance their weaker (left) foot and then the stronger (right) foot. This allows the cane to provide support on the weaker side.
C. This action is correct for a client with left-sided hemiparesis. The quad cane should be held on the stronger side (right hand) to provide support for the weaker side (left leg).
D. This statement is unclear in terms of the context provided. However, typically when using a quad cane, the cane is moved forward a comfortable distance with each step to provide continuous support and balance. The exact distance may vary depending on the client's stride length and comfort.
Correct Answer is C
Explanation
C. Using a raised toilet seat helps maintain the hips above the knees, which is recommended after THA to reduce strain on the hip joint and facilitate safer toileting. Keeping the hips higher than the knees helps prevent excessive flexion of the hip joint, which can strain the surgical site.
A Twisting at the waist places stress on the hip joint and can increase the risk of dislocation, which is a significant concern after THA surgery.
B. This option does not specify the correct procedure for using a walker
D. Heat application, such as using a heating pad, is not recommended for the operative hip after THA. Heat can increase blood flow and inflammation, potentially worsening pain and swelling.
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