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.
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Correct Answer is C
Explanation
A. Varicella-zoster requires airborne and contact precautions due to the highly contagious nature of chickenpox (varicella) and shingles (zoster).
B. Vancomycin-resistant enterococcus (VRE) typically requires contact precautions to prevent transmission.
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Correct Answer is A
Explanation
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A. A BMI of 20 falls within the healthy weight range for adults.
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C. Overweight is characterized by a BMI between 25 and 29.9.
D. Obesity is characterized by a BMI of 30 or higher.
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