A nurse is assessing a client with an AV fistula. Which of the following assessments should the nurse perform to evaluate the function of the AV fistula? (Select All that Apply.)
Observe the client's skin color and temperature in the affected arm
Measure the blood pressure in the affected arm
Auscultate for the presence of a bruit over the fistula
Palpate the fistula for a thrill
Assess the client's cognitive status
Assess the client's respiratory rate
Correct Answer : A,C,D
A: Monitoring the skin color and temperature can help identify complications such as thrombosis or infection in the fistula arm.
B: Blood pressure measurement in the fistula arm should be avoided because it may cause damage to the fistula.
C: A bruit indicates proper blood flow through the fistula, which is essential for function.
D: A thrill is a palpable vibration that should be present if the fistula is functioning correctly.
E: Cognitive status is not relevant to evaluating the function of the AV fistula.
F: Respiratory rate is unrelated to assessing the fistula's function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A: Joining the conversation and supporting one side could escalate the situation and further compromise professionalism.
B: Ignoring the situation may allow unprofessional behavior to continue and could impact team dynamics.
C: It is best to address the situation by suggesting they move the conversation to a private area, ensuring professionalism and confidentiality.
D: Reporting the nurses immediately without intervening is premature; it is better to suggest a more private and professional approach.
Correct Answer is B
Explanation
A: A Doppler at the antecubital fossa is not specific for AV graft patency.
B: A bruit (whooshing sound) heard through auscultation and a palpable thrill (vibration) over the AV graft indicate patency and normal function.
C: BP comparison doesn’t assess AV graft function.
D: Peripheral pulses don’t give specific information about graft flow.
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