Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank

After the insertion of an arteriovenous graft in the right forearm, a patient reports pain and coldness of the right fingers. Which action should the nurse take? a. Remind the patient to take a daily low-dose aspirin tablet. b. Report the patient's symptoms to the health care provider. c. Elevate the patient's arm on pillows above the heart level. d. Teach the patient about normal arteriovenous graft function. - ANS: B The patient's problems suggest the development of distal ischemia (steal syndrome) and may require revision of the AVG. Elevating the arm above the heart will further decrease perfusion. Pain and coolness are not normal after AVG insertion. Aspirin therapy is not used to maintain grafts. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity Which assessment finding should the nurse expect when a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30? a. Persistent skin tenting b. Rapid, deep respirations c. Hot, flushed face and neck d. Bounding peripheral pulses - ANS: B Patients with metabolic acidosis caused by AKI may have Kussmaul respirations to eliminate carbon dioxide. Bounding pulses and vasodilation are not associated with metabolic acidosis. Because the patient is likely to have fluid retention, poor skin turgor would not be a finding in AKI. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity The nurse is planning care for a patient with severe heart failure who has developed increased blood urea nitrogen (BUN) and creatinine levels. What will be the primary treatment goal in the plan?