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 C

Explanation

C. Monitoring urine output is crucial in the early postoperative period after a kidney transplant to assess kidney function and ensure adequate perfusion.

A Managing pain is important, but the administration of opioids should be carefully considered due to their potential to mask symptoms and side effects that could be critical in the postoperative period.

B. While electrolyte imbalances are important to monitor, hypokalemia specifically is not typically associated with acute rejection in the early postoperative period.

D. Blood pressure monitoring every 8 hours may not be sufficient in the immediate postoperative period, especially given the potential for fluid shifts and changes in hemodynamic status.

A. Ventrogluteal B. Vastus lateralis C. Dorsogluteal D. Deltoid

Correct Answer is B

Explanation

B. This location is preferred because it provides rapid and higher peak plasma epinephrine levels compared to other sites, which is crucial during an anaphylactic emergency.

A While this can be a safe IM injection site in some adults, it's not the preferred location for epinephrine during anaphylaxis. The muscle mass in the ventrogluteal area might be less reliable for quick absorption of the medication in an emergency situation.

C. avoided due to its proximity to major nerves (sciatic nerve) and blood vessels, which can lead to complications such as nerve damage or accidental injection into a blood vessel.

D. The deltoid is generally not recommended because it has a smaller muscle mass compared to the ventrogluteal or vastus lateralis sites.

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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?

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