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.

Answer and Explanation

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. Lowering the bed height reduces the risk of injury in case the client falls out of bed. It also facilitates easier transfers for clients with mobility issues.

A Individuals with dementia may experience disorientation and confusion, especially in unfamiliar or dark environments. Turning off all lights can increase the risk of falls and accidents.

B. Clients with dementia may have difficulty recognizing the need to toilet or may forget where the bathroom is located. They may also have urinary or fecal incontinence. Scheduled toileting helps prevent accidents and promotes continence.

D. Sedatives or hypnotic medications can increase confusion, risk of falls, and adverse effects in older adults with dementia. They are generally not recommended as first-line treatment for sleep disturbances in dementia.

A. Bradycardia B. Photophobia C. Petechiae on the chest D. Intermittent headache

Correct Answer is B

Explanation

B. Photophobia, or sensitivity to light, is a common symptom in clients with meningitis. It occurs due to irritation of the meninges and the optic nerve by the inflammatory process. Clients may avoid bright lights and prefer dimly lit environments to reduce discomfort.

A Bradycardia (slow heart rate) is not typically associated with meningitis. In fact, many clients with meningitis may present with tachycardia (fast heart rate) due to fever, dehydration, and systemic inflammation. Therefore, bradycardia is not an expected finding in meningitis.

C. Petechiae (small red or purple spots) on the chest can occur in bacterial meningitis, particularly in cases caused by Neisseria meningitidis. These petechiae are often seen in clusters and can indicate disseminated intravascular coagulation (DIC), a serious complication associated with meningococcal infection. However, they are less specific

D. Headache is a hallmark symptom of meningitis, typically described as severe and persistent. It is often accompanied by other symptoms such as fever, neck stiffness (nuchal rigidity), photophobia, and altered mental status. Headache in meningitis is usually continuous rather than intermittent.

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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?

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Naxlex Comprehensive Predictor Exams

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