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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: While requiring assistance with getting dressed is an important consideration in care planning, it is not the most immediate priority. The nurse should ensure that the client's basic needs are met, but this does not represent an acute medical concern.

Choice B reason: The client reporting numbness of the fingers of the left hand is the most urgent priority. Numbness can indicate neurovascular compromise or increased pressure within the cast, which could lead to further injury or complications such as compartment syndrome. Immediate assessment and intervention are required to prevent permanent damage.

Choice C reason: Itching of the left arm under the cast is a common complaint and can be uncomfortable for the client. However, it is not a priority over potential neurovascular compromise. The nurse can provide education on how to safely alleviate itching without compromising the integrity of the cast.

Choice D reason: Having a pillow under the left arm is part of proper positioning to reduce swelling and provide comfort. While it is a part of good nursing care, it is not a priority over signs of neurovascular compromise.

A. Uric acid B. Intrinsic factor C. Chloride level D. Creatinine kinase

Correct Answer is A

Explanation

Choice A reason : Uric acid levels are expected to be increased in a client with acute gout. Gout is associated with hyperuricemia, where serum or plasma urate concentrations exceed 6.8 mg/dL. This elevation in uric acid can lead to the formation of monosodium urate crystals in joints, causing the characteristic painful inflammation of gout.

Choice B reason : Intrinsic factor is not related to gout. It is a protein produced by the stomach that is necessary for the absorption of vitamin B12.

Choice C reason : Chloride levels are typically not affected in acute gout and are not a specific indicator for this condition.

Choice D reason : Creatinine kinase is an enzyme found in the heart, brain, skeletal muscle, and other tissues. Elevated levels may indicate muscle damage but are not a specific marker for gout.

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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?

Nursing Test Bank

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