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.

Answer and Explanation

The Correct Answer is 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.

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Correct Answer is C

Explanation

- A: Garlic supplements are not contraindicated for clients taking antidepressants. While garlic is known to have a variety of health benefits, there is no well-documented interaction between garlic supplements and antidepressants that would contraindicate their concurrent use.
- B: There is no direct contraindication for the use of garlic supplements in clients with a history of seizure disorders. Garlic supplements do not have a seizure threshold-lowering effect, which is a common concern with some medications and conditions that may exacerbate seizure disorders.
- C: Garlic supplements may increase the risk of bleeding, especially when taken with other substances that have anticoagulant properties, such as aspirin. This is due to garlic's potential effect on platelet aggregation and the blood clotting process, making it a contraindication for clients who take aspirin daily.
- D: Garlic supplements do not have a contraindication for clients with a history of rheumatoid arthritis. In fact, some studies suggest that garlic may have anti-inflammatory properties, which could be beneficial for individuals with inflammatory conditions like rheumatoid arthritis.

A. Perform active range-of-motion exercises. B. Maintain the head at a midline position. C. Suction the airway frequently. D. Perform neurological checks every 4 hours.

Correct Answer is B

Explanation

A. Active range-of-motion exercises are not appropriate for a child with increased intracranial pressure and decreased level of consciousness, as they may increase intracranial pressure.

B. Maintaining the head at a midline position helps promote proper cerebral perfusion and reduces the risk of further increases in intracranial pressure.

C. Frequent suctioning of the airway can stimulate the gag reflex and increase intracranial pressure. Suctioning should only be done as needed to maintain a clear airway.

D. Neurological checks should be performed more frequently than every 4 hours in a child with increased intracranial pressure and decreased level of consciousness, ideally at least every hour or as indicated by the child's condition.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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