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: White rice is considered a low-potassium food, making it a suitable option for someone with chronic kidney disease who needs to limit their potassium intake. One cup of cooked white rice contains approximately 54 mg of potassium, which is significantly lower than the other options listed.
Choice B reason: Nonfat yogurt can vary in potassium content, but on average, a 1/2 cup serving may contain around 200 to 300 mg of potassium. While it is a nutritious choice, it contains more potassium than white rice and should be consumed in moderation by individuals with potassium restrictions.
Choice C reason: A medium baked potato with skin is high in potassium, with one potato containing over 900 mg of potassium. This makes it an unsuitable choice for someone who needs to limit their potassium intake due to chronic kidney disease.
Choice D reason: Peanut butter contains a moderate amount of potassium. Two tablespoons of peanut butter can have around 150 to 200 mg of potassium. Although it's not as high in potassium as a baked potato, it still contains more potassium than white rice.
Correct Answer is C
Explanation
Choice A reason: A respiratory rate of 24/min is slightly higher than the normal range (12-20 breaths per minute) and does not necessarily indicate the effectiveness of furosemide in treating pulmonary edema.
Choice B reason: Adventitious breath sounds, such as crackles or wheezes, are often present in pulmonary edema and would not indicate that the furosemide is effective. The resolution of these sounds would be a better indicator of improvement.
Choice C reason: Weight loss of 1.8 kg (4 lb) in the past 24 hours likely indicates a reduction in fluid retention, which is a desired effect of furosemide in the treatment of pulmonary edema. This diuretic effect reduces the fluid overload, thereby improving the symptoms of pulmonary edema.
Choice D reason: An elevation in blood pressure is not an expected outcome of effective furosemide therapy for pulmonary edema. Furosemide is a diuretic and would more likely lead to a reduction in blood pressure due to fluid loss.
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