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. A bed alarm is a device that triggers an alert when the client attempts to get out of bed or leaves a designated area. Bed alarms can be effective in alerting nursing staff to the client's movements, allowing for timely intervention to prevent wandering and ensure the client's safety. This intervention is commonly used in healthcare settings to monitor clients at risk for falls or wandering.

A Moving the client to a double room may not necessarily prevent wandering. In fact, it could potentially increase the risk if the client wanders into another resident's space or attempts to leave the room altogether.

B. Using chemical restraints (such as medications to sedate or calm the client) is not recommended unless absolutely necessary for the safety of the client or others. It does not address the underlying cause of wandering and can have significant adverse effects on the client's health and well-being.

D. Providing excessive stimulation can overwhelm and agitate clients with dementia, potentially worsening behaviors such as wandering. It is important to offer activities that are calming, engaging, and appropriate for the client's cognitive abilities.

A. Client report of nausea B. Serosanguineous drainage C. Muscle twitching D. Client report of incisional pain

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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