A nurse is planning care for a client who is postoperative following creation of an arteriovenous fistula in the left arm. Which of the following actions should the nurse include in the plan?
Auscultate the client's left arm for a bruit every 4 hours.
Compare blood pressure in both arms every 2 hours.
Instruct the client to keep the left arm in a dependent position.
Encourage the client to restrict movement of the left arm.
The Correct Answer is A
A.
A. Auscultating the client's left arm for a bruit helps assess the patency and function of the arteriovenous fistula. A bruit indicates normal blood flow through the fistula.
B. Comparing blood pressure in both arms every 2 hours is not specifically related to monitoring the arteriovenous fistula. Blood pressure comparison may be done periodically but is not as directly relevant to postoperative care of the fistula.
C. Instructing the client to keep the left arm in a dependent position may help with venous return but is not the primary action for monitoring the arteriovenous fistula's patency and function.
D. Encouraging the client to restrict movement of the left arm is not necessary unless there are specific instructions from the surgeon. Encouraging gentle movement and range of motion exercises may actually be beneficial for preventing stiffness and promoting healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The water seal chamber should contain at least 2 cm of water to maintain the seal and prevent air from entering the pleural space. Only 1 cm of water is inadequate and requires intervention.
B. Tidaling, or fluctuation of water with respirations, is an expected finding and indicates that the system is functioning properly.
C. A suction chamber pressure of -20 cm H₂O is the standard setting for chest tube drainage systems and does not require intervention.
D. A drainage collection chamber that is one-third full is within normal limits and simply indicates the need to continue monitoring output.
Correct Answer is D
Explanation
A. Restricting dietary calcium intake is not typically recommended for preventing nephrolithiasis; in fact, adequate calcium intake may decrease the risk of kidney stone formation.
B. Limiting fluid intake is not recommended for individuals with nephrolithiasis; adequate fluid intake helps prevent kidney stone formation.
C. Complex carbohydrates do not significantly impact the risk of nephrolithiasis; dietary changes should focus on other factors such as oxalate intake.
D. Foods high in oxalates, such as spinach, beets, nuts, and chocolate, can contribute to the formation of kidney stones in susceptible individuals, so it's important to avoid them.
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