A nurse is planning care for a client who has a newly implanted arteriovenous graft in the right arm. Which of the following actions should the nurse include in the plan of care?
Insert a saline lock into a site 10 cm (4 in) distal to the graft.
Instruct the client to avoid lifting the right arm for 72 hr.
Palpate the site for a thrill.
Check blood pressure in the right arm.
The Correct Answer is C
Palpating the site for a thrill is an important action to assess the patency and function of an arteriovenous graft, which is a synthetic tube that connects an artery and a vein for hemodialysis access. A thrill is a vibration felt over the graft that indicates blood flow. The other options are incorrect because they could compromise or damage the graft.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Allow the client to sign the consent with an X. The client has the right to give informed consent if they understand the procedure and its risks and benefits, even if they cannot read or write. The nurse should witness and document the client's signature with an X and verify their identity and understanding. The other options are not appropriate because they violate the client's autonomy and dignity.
Correct Answer is D
Explanation
This response assesses the client's understanding and adherence to the antiretroviral therapy (ART), which isessential for managing HIV and preventing complications and transmission. ART requires strict adherence to a specific regimen of medications that must be taken at certain times and with certain foods or fluids.
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