The nurse plans care for a client receiving hemodialysis (HD) every third day. Which is the priority nursing goal?

Question

1. Palpate the thrill of client's AV fistula.
2. Maintain integrity of client's AV fistula.
3. Provide low potassium foods with meals.
4. Maintain the fluid and electrolyte balance.

Answer 1

2
2. The most important nursing goal for the client receiving HD is to maintain the in-tegrity of the AV fistula because it is the access device for the client's HD and HD is vital to maintaining the client's life. AV fistulas are delicate structures that require protection to function; trauma, pressure, and inadvertent phlebotomy can permanently damage the fistula. The nurse plans nursing interventions to accomplish the goal, including palpating the fistula thrill and posting signs directing ancillary personnel to avoid the arm with the fistula.
1. Palpating the fistula thrill is a nursing intervention that supports the nurse's priority nursing goal.
3. Meals with restricted potassium content are important for a client with renal failure because the client is unable to clear solute from the blood, especially potassium.
4. A goal for the client receiving HD is maintaining fluid and electrolyte balance and a supporting nursing intervention includes potassium-restricted meals; protecting the fistula is the most important goal because without the fistula the client needs alternate vascular access to dialyze the blood.