NCLEX RN Practice Question # 939

NCLEX Examination.

Practice Question # 939.

 

nclex examination.

 

Interventions for an arteriovenous fistula and arteriovenous graft

  1. Teach the client that the extremity should not be used for monitoring BP, drawing blood, placing IV lines, or administering injections, and that the client should inform all health care personnel of its presence.
  2. Teach the client with an arteriovenous fistula to perform hand-flexing exercises such as ball squeezing (if prescribed) to promote graft maturity.
  3. Note the temperature and capillary refill of the extremity.
  4. Palpate pulses below the fistula or graft, and monitor for hand swelling as an indication of ischemia.
  5. Monitor for clotting.
  6. Complaints of tingling or discomfort in the extremity
  7. Inability to palpate a thrill or auscultate

a bruit over the fistula or graft

  1. Monitor for arterial steal syndrome.
  2. Monitor for infection.
  3. Monitor lung and heart sounds for signs of heart

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