NCLEX-PN

Category - Reduction of Risk

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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?

Administer oral medications
Take vital signs
Palpate for the presence of bruit or thrill over the fistula or graft
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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