NCLEX-PN

Category - Physiological Adaptation

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A nurse is assigned to care for a client who is on hemodialysis. A nurse can safely perform which of the following interventions on the arm with the arteriovenous fistula?

Blood pressure monitoring
Administration of a medication through the intramuscular route
Assist the RN in placing an IV line
Capillary refill assessment

Explanation

Answer: D - The nurse can safely assess the capillary refill and the temperature of the extremity with the arteriovenous fistula. Blood pressure monitoring, intramuscular injections, and placing an IV line are not performed on the extremity with the fistula as it can cause clot formation.

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