NCLEX-PN

Category - Reduction of Risk

A client is admitted for anemia and is undergoing hemodialysis three times a week. During the initial rounds, which of the following actions should the nurse do first?
  1. Administer oral medications
  2. Take vital signs
  3. Palpate for the presence of bruit or thrill over the fistula or graft
  4. Change the dressing of the fistula
Explanation
Answer: C - Palpating or auscultating for bruit or thrill over the fistula allows the nurse to determine which arm should be used to measure blood pressure, draw blood, insert an IV line, and administer medications. AV fistula and graft rarely require dressing because the fistula/graft is internal.
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