The charge nurse is orienting a float nurse to an assigned client ...

[APUS57]

The charge nurse is orienting a float nurse to an assigned client with an arteriovenous (AV) fistula for hemodialysis in her left arm. Which action by the float nurse would be considered unsafe?
 
  a. Palpating the access site for a bruit or thrill
  b. Using the right arm for a blood pressure reading
  c. Administering intravenous fluids through the AV fistula
  d. Checking distal pulses in the left arm

Question 2

A client is having a peritoneal dialysis treatment. The nurse notes an opaque color to the effluent. What is the priority action by the nurse?
 
  a. Warm the dialysate solution in a microwave before instillation.
  b. Take a sample of the effluent and send to the laboratory.
  c. Flush the tubing with normal saline to maintain patency of the catheter.
  d. Check the peritoneal catheter for kinking and curling.

[flannelavenger]

Answer to Question 1

ANS: C
The nurse should not use the arm with the AV fistula for intravenous infusion, blood pressure readings, or venipuncture. Compression and infection can result in the loss of the AV fistula. The AV fistula should be monitored by auscultating or palpating the access site. Checking the distal pulse would be an appropriate assessment.

Answer to Question 2

ANS: B
An opaque or cloudy effluent is the first sign of peritonitis. A sample of the effluent would need to be sent to the laboratory for culture and sensitivity in order to administer the correct antibiotic. Warming the dialysate in a microwave and flushing the tubing are not safe actions by the nurse. Checking the catheter for obstruction is a viable option but will not treat the peritonitis.

[APUS57]

TYSM

[duy1981999]

Excellent