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 B

Explanation

B. Hypotension suggests inadequate perfusion, which could prompt an increase in dopamine dosage to improve blood pressure and perfusion.

A A heart rate of 60/min is within the normal range for adults and may not necessarily indicate a need to increase dopamine dosage unless accompanied by signs of inadequate perfusion

C. Oxygen saturation of 95% is within the normal range and indicates adequate oxygenation. It does not directly inform the need to increase dopamine dosage

D. A respiratory rate of 14/min is within the normal range. Respiratory rate alone does not typically guide dopamine dosage adjustments unless respiratory distress or acidosis indicates poor tissue perfusion.

A. Check pressure points every 12 hr. B. Provide the client with a trapeze bar. C. Remove the weights before changing the client's bedlinens. D. Instruct the client to use their elbows to reposition.

Correct Answer is B

Explanation

B. Providing the client with a trapeze bar allows them to move and reposition in bed independently without compromising the traction on the affected leg.

A Checking pressure points every 2 hours is generally recommended for clients at risk of developing pressure ulcers, but it's not specific to skeletal traction care.

C. Removing the weights prematurely can lead to loss of traction and compromise the therapeutic benefit of the traction.

D. When a client has skeletal traction, they should avoid using the affected limb for any weight-bearing activities or for repositioning

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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

Naxlex Comprehensive Predictor Exams

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