NCLEX® QOTD: AV fistula
Published on Sep 4, 2024. Updated on Sep 4, 2024.
The nurse in the medical unit is caring for a client who had an arteriovenous (AV) fistula placed in their left upper extremity for dialysis 24-hours ago. Which activity(ies) should be avoided in/on the affected extremity? Select all that apply.
A. Having blood drawn
B. Wearing tight jewelry
C. Sleeping on the affected extremity
D. Carrying heavy items
E. Wearing tight shirt sleevesF. Palpating over the AV fistula site
G. Having blood pressure taken
Scroll down for the correct answer!
The correct answers to today's NCLEX-RN® Question are...
A. Having blood drawn
Rationale: Having blood drawn from the extremity with an AV fistula should be avoided to avoid damage to the fistula.
B. Wearing tight jewelry
Rationale: Wearing tight jewelry on the extremity with an AV fistula should be avoided to prevent damage to the fistula.
C. Sleeping on the affected extremity
Rationale: Sleeping on the side of an extremity with an AV fistula should be avoided to prevent damage to the fistula.
D. Carrying heavy items
Rationale: Carrying heavy items with the extremity that has an AV fistula should be avoided to prevent damage to the fistula.
E. Wearing tight shirt sleeves
Rationale: Wearing tight shirt sleeves on the extremity with an AV fistula should be avoided to prevent damage to the fistula.
G. Having blood pressure taken
Rationale: Having blood pressure taken from the extremity with an AV fistula should be avoided to prevent damage to the fistula.
Major Takeaway
The nurse caring for the client with an arteriovenous (AV) fistula as their dialysis access site should teach them how to care for it. The nurse should instruct them to avoid tight clothes or jewelry on the extremity that has the fistula or graft, and to avoid activities that compress the extremity, such as carrying heavy items or sleeping on the affected side. Additionally, the nurse should remind the client that they should not have blood drawn or blood pressure taken from the extremity. The nurse should also teach them how to feel for a vibration, called a thrill, over the access site, and explain that a thrill means the access site is intact and working.
Incorrect answer explanation
F. Palpating over the AV fistula site
Rationale: Feeling, or palpating, for a thrill and bruit is a recommended activity for a client with an AV fistula. This helps ensure the fistula is functioning.
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