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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Correct Answer is C
Explanation
C. During an asthma attack, the airways narrow, making it difficult to exhale. This traps air in the lungs, including carbon dioxide.
A This might be true for someone with poorly controlled asthma, but during an acute attack, the airways are already hypersensitive and constricted in response to triggers.
B. This is the opposite of what happens in asthma. Asthma is characterized by inflammation in the airways.
D. Alveolar elasticity refers to the ability of the air sacs in the lungs to recoil after being inflated. While this can be a problem in some lung diseases, it's not the primary issue in an acute asthma attack.
Correct Answer is C
Explanation
C. Muscle twitching post-thyroidectomy can indicate hypocalcemia, a common complication due to inadvertent damage or removal of the parathyroid glands during surgery. Hypocalcemia can lead to neuromuscular irritability, including muscle twitching, tingling, or tetany.
A Nausea is a common postoperative symptom and can be caused by anesthesia, pain medications, or changes in gastrointestinal function. While uncomfortable, nausea alone is typically not an urgent concern
B Serosanguineous drainage (thin, pink-tinged fluid) from the surgical incision is expected in the early postoperative period. It indicates normal wound healing and does not usually require urgent attention
D. Routine incisional pain does not typically require urgent reporting unless accompanied by other concerning symptoms.
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