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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A Hydrogen peroxide can be too harsh and irritating to inflamed oral mucosa. It may further aggravate mucositis and delay healing. Therefore, it is not appropriate to recommend rinsing with hydrogen peroxide for a client with mucositis.
B. Brushing for 60 seconds is not enough.
C. Dentures can exacerbate mucositis by causing friction and pressure on the gums and oral mucosa. To reduce irritation, clients should remove dentures when not eating to give their gums and oral tissues a chance to rest and recover.
D. Flossing can help remove food particles and plaque from between the teeth, which could otherwise contribute to infection.
Correct Answer is D
Explanation
D. An oral airway is a device used to maintain a patent airway by preventing the tongue from obstructing the throat. It can be useful during or after a seizure to ensure the client can breathe effectively and to prevent airway obstruction due to tongue relaxation or loss of muscle tone.
A Wrist restraints are used to immobilize a client's wrists and are not typically indicated for seizure management. Restraining a client during a seizure can increase the risk of injury and hinder appropriate assessment and care
B. Nasogastric (NG) tubes are used for enteral feeding, medication administration, or gastric decompression. They are not directly related to managing seizures and are not typically required during or after a seizure episode. Therefore, an NG tube is not necessary in the client's room for seizure management.
C. Tongue blades are used to depress the tongue for examination of the mouth and throat, but they are not recommended during or immediately after a seizure. There is a common misconception that placing a tongue blade in the mouth prevents the tongue from being bitten during a seizure, but this can actually cause more harm, such as injury to the teeth or gums, during involuntary movements.
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