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
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.
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