The nurse is assessing the arteriovenous fistula in the patient’s right arm; it is without thrill or bruit. Which action does the nurse take next?

Following an industrial accident, the patient is immobile. The student nurse is creating a care plan for the patient to prevent respiratory decompensation. Which intervention, if included in the care plan for this nursing diagnosis, would prompt the nurse to provide additional education to the student nurse?

The patient is brought to the emergency department complaining of sudden onset crushing substernal chest pain. He is pale, diaphoretic, and can only speak in short sentences. His vital signs are notable for a heart rate of 118 bpm, respiratory rate of 22, and a blood pressure of 94/52 mmHg. Upon assessment, peripheral pulses are palpable but weak; lungs are clear; mild jugular venous distention is noted. The emergency medical services administered aspirin on arrival to the scene. The nurse anticipates performing which intervention first?