Question

A client experiencing end-stage kidney disease has an arteriovenous (AV) fistula placed surgically for hemodialysis. Which action is most appropriate for the nurse to document in the plan for care of the AV fistula?

1.Palpate the bruit of the AV fistula weekly to assess for thrombosis.
2.Use the AV fistula site for blood draws to prevent increased pain of multiple blood draws.
3.Take the blood pressure readings in the extremity with the AV fistula to get a more accurate reading.
4.Teach the client to avoid carrying heavy objects that would compress the AV fistula and cause thrombosis.

Answer 1

The nurse should teach the client to avoid carrying heavy objects on the arm with the AV fistula to prevent thrombosis and ensure it remains functional for hemodialysis. So, correct option is (4).

Step-by-step explanation:

The most appropriate action for the nurse to document in the plan for care of an arteriovenous (AV) fistula in a client with end-stage kidney disease is to teach the client to avoid carrying heavy objects that would compress the AV fistula and cause thrombosis.

This instruction is critical because maintaining the patency of the AV fistula is essential for hemodialysis, which the patient needs to clear waste products from their blood. It is important not to use the AV fistula site for blood draws or to take blood pressure measurements in that extremity, as these actions could damage the fistula.

Meanwhile, palpating for a bruit is done to assess the functioning of the AV fistula, but it does not have to be limited to a weekly schedule as this can vary based on the patient's condition and protocol.

An AV fistula is a connection between an artery and a vein, created surgically to provide access for hemodialysis. It is important to protect the AV fistula from injury or compression to prevent complications such as blockage or clots.