Question

A nurse is planning care for a client who is receiving hemodialysis via an established arteriovenous (AV) fistula in the right arm. Which of the following interventions should the nurse include in the client's plan of care?

A) Avoid taking blood pressure measurements on the right arm
B) Apply a warm compress to the AV fistula site before dialysis
C) Encourage the client to sleep on the right side to promote circulation
D) Administer heparin before each dialysis session

Answer 1

The nurse should avoid taking blood pressure measurements on the right arm when caring for a client with an AV fistula. Applying a warm compress and sleeping on the right side are not recommended. Heparin may be administered before each dialysis session.

Step-by-step explanation:

The nurse should include the intervention of avoiding taking blood pressure measurements on the right arm in the client's plan of care. This is because an AV fistula in the right arm can be easily damaged, potentially causing complications and compromising dialysis effectiveness. Blood pressure measurements should be taken on the left arm or on a non-fistula arm to minimize the risk.

Applying a warm compress to the AV fistula site before dialysis is not necessary and may cause discomfort or potential damage to the fistula. Encouraging the client to sleep on the right side is also not recommended, as it can put pressure on the fistula site and potentially disrupt the dialysis process.

Administering heparin before each dialysis session is a common practice to prevent blood clotting during the procedure.