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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Compartment syndrome is a condition characterized by increased pressure within a muscle compartment, leading to impaired blood flow and potential tissue damage. It can occur when swelling or bleeding within a confined space, such as a cast, causes increased pressure on the surrounding tissues.

Tingling in the toes and decreased sensation can be indicative of nerve compression or damage due to increased pressure in the compartment. It is important to recognize these neurological changes as potential signs of compartment syndrome.

Signs and symptoms of compartment syndrome may include:

Severe pain that is out of proportion to the injury or not relieved by pain medication.
Swelling and tightness in the affected area.
Numbness or tingling.
Pale or cool skin over the affected area.
Weakness or decreased sensation in the affected limb.
In severe cases, paralysis or loss of pulse in the affected area.

A. Asking for nausea B. Evaluating for sacral redness C. Checking the respiratory rate D. Auscultating bowel sounds

Correct Answer is C

Explanation

Morphine is a potent opioid analgesic that can depress the respiratory system. Respiratory depression is a potential adverse effect of morphine, and it is essential for the nurse to monitor the patient's respiratory rate regularly to ensure adequate oxygenation and prevent respiratory complications.

By checking the respiratory rate, the nurse can assess if the patient is breathing adequately and detect any signs of respiratory depression. If the respiratory rate is significantly decreased or the patient shows signs of respiratory distress (e.g., shallow or irregular breathing), immediate intervention is necessary to address the situation promptly.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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