Question

A nurse is planning care for a client receiving HD from an AV fistula in the R arm. Which intervention should the nurse include in the plan of care?

A. Measure the blood pressure in the affected arm.
B. Avoid using the affected arm for blood draws.
C. Apply a warm compress to the AV fistula site.
D. Encourage range of motion exercises in the affected arm.

Answer 1

The nurse should avoid using the affected arm with an AV fistula for blood pressure measurements and blood draws to protect the integrity of the fistula, which is vital for hemodialysis.

Step-by-step explanation:

In planning care for a client with an arteriovenous (AV) fistula in the right arm used for hemodialysis (HD), it is important to protect the integrity of the fistula. The correct intervention should include avoiding the use of the affected arm for blood pressure measurements and other procedures that could potentially damage the fistula. Therefore, the nurse should avoid using the affected arm for blood draws or placing a blood pressure cuff on it. Measuring blood pressure on the arm with an AV fistula can cause harm and potentially ruin the fistula. It is recommended instead to use the other arm for blood pressure measurements and any IV insertions or blood draws.