A nurse is planning care for a client who is postoperative following the 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.
Keep the left forearm below the level of the heart.
Collect blood specimens from the graft.
Splint the left forearm to prevent damage to the graft.
The Correct Answer is A
Choice A reason: Checking the pulse distal to the graft is essential to ensure that the graft is patent and that there is adequate blood flow to the distal extremity. A palpable pulse indicates that the graft is functioning properly and not occluded. The absence of a pulse could signify a serious complication, such as thrombosis or stenosis, which requires immediate attention.
Choice B reason: Keeping the left forearm below the level of the heart is not recommended as it can increase venous pressure and swelling, potentially compromising graft function. The extremity should be kept at or above heart level to promote venous return and reduce the risk of edema.
Choice C reason: Collecting blood specimens from the graft is generally avoided to prevent damage to the graft. Blood draws can be performed from other sites to protect the integrity of the graft.
Choice D reason: Splinting the left forearm is not a standard postoperative care measure for an arteriovenous graft. While protecting the graft from injury is important, immobilization with a splint is not necessary and can impede mobility and circulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason : Muscle twitching can be indicative of hypocalcemia, a common and serious complication following a complete thyroidectomy due to potential damage or removal of the parathyroid glands. Hypocalcemia requires immediate intervention to prevent more severe symptoms such as tetany or cardiac complications.
Choice B reason : While nausea is a common postoperative symptom, it is not typically as urgent as signs of hypocalcemia. However, persistent nausea should still be addressed as it can affect the client's comfort and nutritional intake.
Choice C reason : Serosanguineous drainage is expected to some extent after surgery, but if it is excessive or changes in character, it may indicate hemorrhage or infection, which would then become a priority.
Choice D reason : Incisional pain is also expected postoperatively. While pain management is important for recovery, it is not as immediately concerning as potential hypocalcemia unless the pain is severe or uncontrolled, suggesting complications.
Correct Answer is B
Explanation
Choice A reason: This statement does not indicate a need for further instruction. It is recommended to wait at least 30 minutes after taking alendronate before taking other medications to ensure proper absorption of the drug.
Choice B reason: This statement indicates a need for further instruction. Alendronate should be taken with plain water, not milk. Milk and other dairy products can interfere with the absorption of alendronate due to their calcium content.
Choice C reason: This statement does not indicate a need for further instruction. Patients are advised to remain upright for at least 30 minutes after taking alendronate to prevent esophageal irritation or ulceration.
Choice D reason: This statement does not indicate a need for further instruction. Periodic bone density tests are a standard part of monitoring the effectiveness of osteoporosis treatment.
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