Question

When caring for a patient with a left arm arteriovenous fistula, which action will the nurse include in the plan of care to maintain the patency of the fistula?

a. Auscultate for a bruit at the fistula site.
b. Assess the quality of the left radial pulse.
c. Compare blood pressures in the left and right arms.
d. Irrigate the fistula site with saline every 8 to 12 hours

Answer 1

To maintain the patency of a left arm arteriovenous fistula, the nurse should include the action of auscultating for a bruit at the fistula site in the plan of care. Assessing the quality of the left radial pulse, comparing blood pressures in the left and right arms, and irrigating the fistula site with saline every 8 to 12 hours are not appropriate actions for maintaining fistula patency.

Step-by-step explanation:

To maintain the patency of a left arm arteriovenous fistula in a patient, the nurse should include the action of auscultating for a bruit at the fistula site in the plan of care. A bruit is a humming or buzzing sound that indicates blood flow through the fistula. By listening for the bruit, the nurse can assess whether the fistula is functioning properly.

Assessing the quality of the left radial pulse is not an appropriate action for maintaining the patency of an arteriovenous fistula. The radial pulse is distal to the fistula site and is not directly related to its patency.

Comparing blood pressures in the left and right arms is also not an appropriate action for maintaining the patency of an arteriovenous fistula. Blood pressure measurement does not provide direct information about the patency of the fistula.

Irrigating the fistula site with saline every 8 to 12 hours is not necessary for maintaining the patency of an arteriovenous fistula. In fact, it may increase the risk of infection and should be avoided unless specifically indicated.