When the nurse caring for a patient with an AV fistula in the forearm assesses that there is an absence of a "trill" when palpating the venous side of the fistula, the nurse should:
1. inject the ordered amount of heparin into the fistula.
2. apply warm compresses and lower the arm below heart level.
3. send the patient to dialysis for remedy.
4. report to the charge nurse that the fistula is occluded.
4
If there is no trill, the fistula is occluded and should be reported. Dialysis is not possible with the occlusion. Injecting the shunt is not in the scope of practice of the LPN. Warm compresses are not helpful.
PTS: 1 DIF: Cognitive Level: Application REF: 874
OBJ: 5 TOP: Occluded Fistula
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
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