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: Administering oxygen at 2 L/min is appropriate for clients with emphysema who have hypoxemia. Oxygen therapy should be titrated based on the client's oxygen saturation levels to avoid suppressing the respiratory drive.
Choice B reason: The use of incentive spirometry is beneficial for clients with emphysema as it encourages deep breathing and helps prevent atelectasis. It is an appropriate intervention to include in the plan of care.
Choice C reason: Breathing exercises for clients with emphysema typically focus on prolonging the exhalation phase, not the inhalation phase, to improve airway clearance and reduce the work of breathing.
Choice D reason: Limiting fluid intake is not generally recommended for clients with emphysema unless there are specific contraindications. Adequate hydration can help thin secretions and improve mucus clearance.
Correct Answer is B
Explanation
Choice A reason : Pressing down on the orbital area of the eye is not a recommended method for eliciting a response from a painful stimulus in an unresponsive patient due to the potential for injury to the eye.
Choice B reason : Pressing down on the trapezius muscle is an acceptable method for eliciting a response from a painful stimulus in an unresponsive patient. This technique is less invasive and can be performed safely to assess the patient's level of consciousness or response to pain without causing harm⁸.
Choice C reason : Using a 25-gauge needle is not an appropriate method for eliciting a response from a painful stimulus in an unresponsive patient. This could cause unnecessary harm and is not a standard practice in clinical settings.
Choice D reason : Eliciting a reflex with a reflex hammer is a method used to assess reflexes, not to elicit a response from a painful stimulus in an unresponsive patient. This tool is used to test neurological function and reflex integrity, not to assess pain response.
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