A nurse is planning care for a client who is postoperative following insertion of an arteriovenous graft in their left forearm. Which of the following actions should the nurse include in the plan of care?

Check the pulse distal to the graft.

Splint the left forearm to prevent damage to the graft.

Collect blood specimens from the graft.

Keep the left forearm below the level of the heart.

Answer and Explanation

The Correct Answer is A

A Checking the pulse distal (beyond) to the AV graft site is crucial to assess peripheral circulation. It helps determine if the graft is adequately perfusing blood to the distal extremity. Absence or weak pulse distal to the graft could indicate graft malfunction or complications such as thrombosis or inadequate blood flow.

B. Splinting the forearm may help immobilize the arm and reduce movement that could potentially disrupt the AV graft site. However, immobilization should be balanced with promoting mobility and preventing complications such as joint stiffness or pressure injuries.

C. Drawing blood from the AV graft could introduce infection risk or damage the graft site. It is standard practice to avoid using the AV graft for routine blood draws

D. Positioning the forearm below the level of the heart promotes venous return and reduces swelling or edema in the extremity. However, for an AV graft, maintaining the arm in a dependent position should be avoided to prevent excessive pressure on the graft site or compromising blood flow.

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Correct Answer is D

Explanation

D. Paraplegia significantly increases the risk of skin breakdown due to immobility, lack of sensation, and prolonged pressure on specific areas of the body. These clients require meticulous skin care and frequent repositioning to prevent pressure injuries.

A While urinary incontinence can contribute to skin breakdown, especially if not managed properly, it may not pose as great a risk compared to other factors like poor nutrition or immobility.

B. Poor nutrition compromises skin integrity by reducing the skin's ability to repair and maintain itself, making it more susceptible to breakdown. This factor significantly increases the risk of developing pressure ulcers and other skin lesions.

C. Clients with Alzheimer's disease may have increased risk due to various factors such as mobility issues, impaired sensation, and difficulty with self-care. However, the degree of risk can vary depending on the stage of the disease and individual circumstances.

A. Remain at least 1 foot away from young children during treatment. B. Use cloth handkerchiefs instead of disposable tissues. C. Use absorbent briefs for incontinence as needed. D. Flush the toilet with the lid closed three times after use.

Correct Answer is D

Explanation

D. This practice is recommended as a safety precaution to minimize the risk of radioactive contamination following treatment with radioactive isotopes. It helps to ensure that any residual radioactivity is contained and not inadvertently spread, which is particularly important in shared or public bathrooms.

A The recommended distance is typically at least 1 meter (approximately 3 feet), although specific guidelines may vary depending on the type and dose of radiation used.

B. The use of cloth handkerchiefs versus disposable tissues does not significantly affect radiation safety. The focus should be on minimizing contamination and ensuring proper disposal of any tissues or materials that come into contact with bodily fluids.

C. While managing incontinence appropriately is important for comfort and hygiene, it is not directly related to radiation safety. Clients should use standard incontinence products as needed, ensuring proper disposal and hygiene practices.

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A nurse is planning care for a client who is postoperative following insertion of an arteriovenous graft in their left forearm. Which of the following actions should the nurse include in the plan of care?

Nursing Test Bank

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