A nurse is caring for a client who has a new arteriovenous (AV) graft in his left forearm. Which of the following techniques should the nurse use to assess the patency of this graft?

Auscultate the site for a bruit.

Measure the client's blood pressure to ensure it is higher in the left arm than the right.

Auscultate the antecubital fossa using a Doppler.

Check the brachial and radial pulses of the left arm simultaneously.

Answer and Explanation

The Correct Answer is A

A. Auscultating for a bruit at the site of an AV graft is the most appropriate method to assess its patency. A bruit is a sound made by turbulent blood flow, indicating that the graft is functioning.

B. Measuring blood pressure in both arms does not specifically assess the patency of the graft and could potentially harm the graft if measured in the affected arm.

C. Auscultating the antecubital fossa using a Doppler is not a standard practice for assessing AV graft patency; instead, a stethoscope is used directly over the graft site.

D. Checking the brachial and radial pulses does not assess the graft directly. Although pulse presence is important, it does not provide information about the graft’s patency.

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Correct Answer is A

Explanation

A. Slow, steady bubbling in the suction control chamber indicates that the system is functioning correctly. The nurse should continue to monitor the client's respiratory status and the drainage system.

B. Clamping the chest tube is not indicated unless instructed by the healthcare provider, as it could lead to a dangerous buildup of pressure in the pleural space.

C. Checking the suction control outlet on the wall is not necessary if the suction control chamber is already bubbling steadily.

D. Checking the tubing connections for leaks is unnecessary if the bubbling is slow and steady, as this indicates the system is working properly.

A. Reduce cholesterol and saturated fat intake. B. Sustain hyperglycemia to reduce deterioration of nerve cells. C. Maintain optimal blood pressure to prevent kidney damage. D. Increase physical activity and daily exercise. E. Enroll in a smoking cessation program.

Correct Answer is ["A","C","D","E"]

Explanation

A. Reducing cholesterol and saturated fat intake is important for managing cardiovascular health, which is crucial for clients with diabetes to prevent complications such as heart disease and stroke.

B. Sustaining hyperglycemia is incorrect; it actually contributes to complications like neuropathy, retinopathy, and nephropathy. The goal is to maintain blood glucose levels within the target range.

C. Maintaining optimal blood pressure is essential in preventing diabetic nephropathy, as high blood pressure can damage the kidneys and worsen diabetic kidney disease.

D. Increasing physical activity helps improve insulin sensitivity, control blood glucose levels, and reduce the risk of complications associated with diabetes.

E. Smoking cessation is critical in reducing the risk of cardiovascular disease, which is higher in clients with diabetes. Smoking can exacerbate the complications of diabetes.

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A nurse is caring for a client who has a new arteriovenous (AV) graft in his left forearm. Which of the following techniques should the nurse use to assess the patency of this graft?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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