A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft?

Palpable thrill

Absence of a bruit

Normotensive blood pressure

Dilated appearance of the graft

Answer and Explanation

The Correct Answer is A

A. A palpable thrill over the graft site indicates adequate blood flow through the graft.

B.   The presence of a bruit (a humming sound) over the graft site is expected and indicates blood flow.
C.   Normotensive blood pressure is not specifically indicative of the circulation of the graft.
D.   A dilated appearance of the graft may indicate an issue with the graft, such as an aneurysm, rather than adequate circulation.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A) The Morse Fall Risk scale assesses the risk of falls in hospitalized patients but is not the priority for a postoperative client with an ORIF.
B) The Braden scale assesses the risk of pressure ulcers and is not the priority for a postoperative client with an ORIF.
C) Pain assessment is important but may not be the priority compared to assessing neurovascular status, especially immediately postoperatively.
D) The neurovascular assessment, including circulation, sensation, and movement, is crucial for early detection of complications such as compartment syndrome or impaired blood flow.

A. Administer the transfusion through a 25-gauge saline lock. B. Administer the plasma immediately after thawing. C. Transfuse the plasma over 4 hr. D. Hold the transfusion if the client is actively bleeding.

Correct Answer is B

Explanation

A) Administering the transfusion through a 25-gauge saline lock might not be appropriate as it may cause hemolysis or obstruct the flow of plasma.
B) Administering the plasma immediately after thawing is crucial to ensure the effectiveness of the transfusion and to prevent degradation of the plasma components.
C) Transfusing the plasma over 4 hours is a standard practice, but the priority is administering it promptly after thawing.
D) Holding the transfusion if the client is actively bleeding is inappropriate since the client is losing blood which needs to be replaced. Furthermore, fresh frozen plasma contains clotting factors which are beneficial for a client whose cause of bleeding is clotting factor deficiencies.

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A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft?

Nursing Test Bank

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