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 C
Explanation
C. An increase in uric acid levels (hyperuricemia) is a hallmark finding in acute gout. Elevated uric acid levels predispose to the formation and deposition of urate crystals in joints, leading to the inflammatory response seen in gout attacks.
A While CK levels can increase in conditions affecting muscles (like rhabdomyolysis), it is not specifically associated with acute gout.
C Uric acid levels are typically elevated during acute gout attacks. This is because gout results from the deposition of urate crystals in the joints due to elevated serum uric acid levels. Therefore, during an acute gout attack, uric acid levels in the blood are often higher than normal.
D. Chloride is an electrolyte and its levels can vary based on hydration status, acid-base balance, and kidney function. It is not directly associated with acute gout, so its levels would not necessarily increase in this condition.
Correct Answer is B
Explanation
B. This location is preferred because it provides rapid and higher peak plasma epinephrine levels compared to other sites, which is crucial during an anaphylactic emergency.
A While this can be a safe IM injection site in some adults, it's not the preferred location for epinephrine during anaphylaxis. The muscle mass in the ventrogluteal area might be less reliable for quick absorption of the medication in an emergency situation.
C. avoided due to its proximity to major nerves (sciatic nerve) and blood vessels, which can lead to complications such as nerve damage or accidental injection into a blood vessel.
D. The deltoid is generally not recommended because it has a smaller muscle mass compared to the ventrogluteal or vastus lateralis sites.
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