A nurse is assessing a client who has an arteriovenous (AV) graft in the right forearm for hemodialysis access. The nurse auscultates a bruit over the graft area. Which intervention should the nurse implement?

Document the findings.

Elevate the extremity.

Apply gentle pressure.

Assess the client’s temperature.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Auscultating a bruit over the graft area of a client who has an arteriovenous (AV) graft in the right forearm for hemodialysis access is a normal finding. A bruit is a vibration felt over the graft that indicates blood flow. Therefore, the nurse should document the findings as it indicates the graft is patent and functioning properly.
Choice B rationale
Elevating the extremity is not necessary in this case. The presence of a bruit indicates that the graft is functioning properly.
Choice C rationale
Applying gentle pressure is not the appropriate intervention in this case. The presence of a bruit is a positive sign indicating the graft is functioning properly.
Choice D rationale
Assessing the client’s temperature is not directly related to the presence of a bruit over the graft area. The temperature would not provide information about the patency or function of the AV graft.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale
Blood pH level is a measure of the acidity or alkalinity of the blood. While it’s an important measure in many medical situations, it’s not directly related to the presence of purulent drainage at a burn wound site.
Choice B rationale
Hematocrit measures the percentage of red blood cells in the blood and is not directly related to the presence of purulent drainage at a burn wound site. Elevated hematocrit may indicate dehydration or hemoconcentration but does not specifically address the issue of wound infection.
Choice C rationale
The White Blood Cell (WBC) count is a key indicator of infection or inflammation in the body. An elevated WBC count can indicate an infection, which could be the cause of the purulent drainage observed at the burn wound site.
Choice D rationale
Platelet count is a measure of the number of platelets in the blood. Platelets are involved in clotting and wound healing, but they do not directly indicate the presence of an infection that could cause purulent drainage.

A. Lean beef, salads, and baked potatoes. B. Potatoes, low-fat breads, and applesauce. C. Oatmeal, raisins, and fruit with skin. D. Chicken, rice, and wheat products.

Correct Answer is C

Explanation

Choice A rationale
While lean beef, salads, and baked potatoes can be part of a balanced diet, they do not specifically target the prevention of colon and rectal cancers. Red meat, in particular, has been associated with an increased risk of colorectal cancer.
Choice B rationale
Potatoes, low-fat breads, and applesauce can be part of a balanced diet, but they do not specifically target the prevention of colon and rectal cancers. A diet rich in whole grains, fruits, and vegetables is more beneficial.
Choice C rationale
A diet rich in oatmeal, raisins, and fruit with skin is high in fiber and antioxidants, which can help reduce the risk of colon and rectal cancers. This is especially important for clients with a strong family history of these cancers.
Choice D rationale
Chicken, rice, and wheat products can be part of a balanced diet, but they do not specifically target the prevention of colon and rectal cancers. A diet rich in whole grains, fruits, and vegetables is more beneficial.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assessing a client who has an arteriovenous (AV) graft in the right forearm for hemodialysis access. The nurse auscultates a bruit over the graft area. Which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with a full-thickness burn covering 40% of their body is exhibiting purulent drainage at the wound site. Before reporting this finding to the healthcare provider, which of the patient’s laboratory values should the nurse review?

Correct Answer is C

Explanation

Which group of foods is best for the nurse to recommend for clients with a strong family history of colon and rectal cancers?

Correct Answer is C

Explanation

While providing care for a patient with Guillain-Barre syndrome, the nurse conducts a neurological assessment every four hours. Which finding from the assessment requires immediate intervention by the nurse?

A client who was recently diagnosed with Raynaud’s disease is concerned about pain management. Which nursing instruction should the nurse provide?

The nurse is educating a client, who was admitted with a blood glucose level of 580 mg/dL, on how to prevent complications related to diabetes mellitus. Which statement made by the client indicates they have understood the information?

The nurse is providing discharge teaching to an older adult patient hospitalized for treatment of venous leg ulcers. Which instructions should the nurse include in the teaching plan? (Select all that apply.)

An hour after administering 60 mg of furosemide intravenously (IV), which assessments should the nurse perform to determine the patient’s response to treatment? (Select all that apply.)

A nurse is educating a patient with Type 2 diabetes mellitus and peripheral neuropathy. What advice should the nurse give?

A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client’s plan of care?

A client receives a prescription for 1 liter of lactated Ringer’s intravenously (IV) to be infused over 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver?