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 C
Explanation
Choice A reason: Injecting the medication into the abdomen above the level of the iliac crest is not recommended. The preferred sites for subcutaneous injections are the fatty tissue over the triceps, the abdomen from below the costal margin to the iliac crests, and the anterior aspects of the thighs. The area above the iliac crest may not have sufficient subcutaneous tissue, which could affect the absorption of the medication.
Choice B reason: Using a 1-inch needle can be appropriate depending on the client's body mass. For most adults, a 5/8-inch to 1-inch needle is recommended for subcutaneous injections to ensure the medication is delivered to the subcutaneous tissue and not into the muscle.
Choice C reason: Using a 25-gauge needle is the appropriate action when administering heparin subcutaneously. A smaller gauge needle, such as 25-gauge, is typically used for subcutaneous injections to minimize discomfort and tissue trauma.
Choice D reason: Massaging the injection site after administration of the medication is not recommended when administering heparin subcutaneously. Massaging the site can cause the medication to be absorbed more quickly than intended and may increase the risk of bleeding.
Correct Answer is C
Explanation
The correct answer is: c. Wear a surgical mask when providing care to the client.
Choice A: Perform a Mantoux skin test on the client
The Mantoux skin test is used to screen for tuberculosis, not pertussis. Pertussis, also known as whooping cough, is a bacterial infection caused by Bordetella pertussis. The Mantoux test would not be relevant or helpful in diagnosing or managing pertussis.
Choice B: Assign the client to a negative-pressure airflow room
Negative-pressure airflow rooms are typically used for airborne infections such as tuberculosis, measles, or varicella. Pertussis is primarily spread through respiratory droplets, not airborne transmission, so a negative-pressure room is not necessary.
Choice C: Wear a surgical mask when providing care to the client
Wearing a surgical mask is appropriate when caring for a client with pertussis. Pertussis is spread through respiratory droplets, and wearing a mask helps prevent the transmission of the bacteria to healthcare workers and other patients.
Choice D: Recommend that the client’s family members receive antiviral therapy
Antiviral therapy is not effective against pertussis, which is a bacterial infection. Instead, antibiotics such as azithromycin or erythromycin are used to treat pertussis and prevent its spread. Therefore, recommending antiviral therapy would not be appropriate.
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