A client has a newly created arteriovenous fistula in the right forearm. For each group, select all responses that apply.
Multiple Response Grouping
Choose your responses, then check the answer.
Explanation
Protect the access arm from compression, blood pressure measurement, venipuncture, and IV insertion. Patency is assessed by regularly palpating the thrill and auscultating the bruit. The absence of either finding requires prompt reporting; it should not be ignored until dialysis. Tight clothing, sleeping on the arm, or applying pressure or heat without an order can impair or injure the access.
Protect the access arm from compression, blood pressure measurement, venipuncture, and IV insertion. Patency is assessed by regularly palpating the thrill and auscultating the bruit. The absence of either finding requires prompt reporting; it should not be ignored until dialysis. Tight clothing, sleeping on the arm, or applying pressure or heat without an order can impair or injure the access.
Key cues
Use only the findings, timing, and orders stated in the scenario.
Clinical reasoning
Apply the requested nursing decision to this client rather than relying on a broad disease label.
Why the alternatives do not fit
The remaining responses are contradicted by the scenario, mistimed, outside scope, or unsafe.
Priority and safety
Address immediate threats first and reassess after intervention.
Takeaway
Choose only actions supported at this exact point in care.
Sources
Open RN Nursing Skills 2e
A client has a newly created arteriovenous fistula in the right forearm. For each group, select all responses that apply.
arteriovenous fistula — arteriovenous fistula is a key clinical concept for assessing and managing hemodialysis access protection.
thrill — thrill is a key clinical concept for assessing and managing hemodialysis access protection.
bruit — bruit is a key clinical concept for assessing and managing hemodialysis access protection.