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?

Incorrect

  • Contact the provider
  • Massage above the site
  • Document the finding as normal; continue the assessment
  • Instruct the patient to hold the arm in the dependent position

Rationale

A bruit heard on auscultation or a thrill felt on palpation indicates adequate flow through the AV fistula. Absence of these signs indicate the fistula may be clotting; the provider should be notified immediately. It is not appropriate to massage above the site or instruct the patient to hold the arm in the dependent position. As this finding is not normal, it would be inappropriate to document as such.

  • Category: Reduction of Risk Potential
  • Difficulty: 6
  • Tags: Acid-Base Communication & Documentation Hematology/Oncology Assessment Cardiovascular Fluid and Electrolytes

Question 45 of 75

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