After the insertion of an arteriovenous graft (AVG) in the right forearm, a patient complains of pain and coldness of the right fingers. Which action should the nurse take?
Teach the patient about normal AVG function.
Elevate the patient's arm on pillows to above the heart level.
Remind the patient to take a daily low dose aspirin tablet
Report the patient's symptoms to the health care provider.
The Correct Answer is D
Pain and coldness in the fingers following AVG placement can indicate impaired blood flow or compromised circulation to the hand. This may be due to complications such as thrombosis (clot formation), graft malfunction, or decreased arterial perfusion. These symptoms should be taken seriously and promptly communicated to the healthcare provider.
The healthcare provider needs to evaluate the patient's symptoms, assess the AVG, and determine the appropriate course of action. Prompt intervention can help prevent further complications and ensure adequate blood flow to the fingers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A blood glucose level of 40 mg/dL indicates severe hypoglycemia, which is a medical emergency requiring immediate attention. Hypoglycemia can lead to confusion, altered mental status, seizures, and loss of consciousness if not treated promptly. Therefore, it is crucial to assess and intervene quickly to raise the patient's blood glucose level to a safe range.
While the other clients mentioned also require attention and appropriate care, the severity and immediate risk associated with severe hypoglycemia make it the priority situation. The nurse should initiate appropriate treatment for hypoglycemia, such as administering glucose or glucagon, and closely monitor the patient's response.
Correct Answer is C
Explanation
Suctioning secretions away from the suture line helps maintain the surgical site's cleanliness and promotes healing. It helps prevent accumulation of mucus or oral secretions that can interfere with the healing process and increase the risk of infection. The nurse should use a gentle suctioning technique to avoid disrupting the surgical site.
Applying Neosporin to the surgical site is not typically recommended unless specifically prescribed by the healthcare provider. It is important to follow the provider's instructions regarding wound care.
Applying elbow immobilizers when not being held is not necessary for cleft lip surgery. Elbow immobilizers are usually used in other surgical procedures or for other reasons, such as preventing contractures.
Feeding increased amounts of formula to prevent weight loss is not an appropriate intervention for the first few days after cleft lip surgery. The surgical site may be sensitive, and the child may experience difficulty with feeding initially. The nurse should provide guidance and support for feeding techniques appropriate for the child, which may include using specialized bottles or positioning techniques.
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