After the insertion of an arteriovenous graft (AVG) in the right forearm, a patient complains of pain and coldness of the right fingers. Which action should the nurse take?
Teach the patient about normal AVG function.
Elevate the patient's arm on pillows to above the heart level.
Remind the patient to take a daily low dose aspirin tablet
Report the patient's symptoms to the health care provider.
The Correct Answer is D
Pain and coldness in the fingers following AVG placement can indicate impaired blood flow or compromised circulation to the hand. This may be due to complications such as thrombosis (clot formation), graft malfunction, or decreased arterial perfusion. These symptoms should be taken seriously and promptly communicated to the healthcare provider.
The healthcare provider needs to evaluate the patient's symptoms, assess the AVG, and determine the appropriate course of action. Prompt intervention can help prevent further complications and ensure adequate blood flow to the fingers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A 3% saline solution is a hypertonic solution used to increase serum sodium levels in cases of severe hyponatremia. However, it can lead to fluid overload and pulmonary edema. The presence of crackles throughout both lung fields indicates the accumulation of fluid in the lungs, which is a serious adverse outcome.
The patient's radial pulse rate of 105 beats/min is within a normal range and does not directly indicate an adverse effect of the saline infusion.
The presence of sediment and blood in the patient's urine may be unrelated to the 3% saline infusion and could indicate other issues such as urinary tract infection or kidney injury.
An increase in blood pressure from 66/50 to 122/74 mmHg is an expected effect of a hypertonic solution like 3% saline, as it can cause an increase in intravascular volume. While the increase in blood pressure is significant, it does not represent an adverse outcome specific to the infusion itself.
Correct Answer is B
Explanation
A blood glucose level of 40 mg/dL indicates severe hypoglycemia, which is a medical emergency requiring immediate attention. Hypoglycemia can lead to confusion, altered mental status, seizures, and loss of consciousness if not treated promptly. Therefore, it is crucial to assess and intervene quickly to raise the patient's blood glucose level to a safe range.
While the other clients mentioned also require attention and appropriate care, the severity and immediate risk associated with severe hypoglycemia make it the priority situation. The nurse should initiate appropriate treatment for hypoglycemia, such as administering glucose or glucagon, and closely monitor the patient's response.
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