Difficulty: Medium
Average Score: 63%
Simulated
The nurse is admitting a client with an arteriovenous (AV) fistula in the right arm for hemodialysis. Which strategy should the nurse plan to implement to best prevent injury to the AV fistula site?
Correct answer
B
Rationale
There should be no venipunctures or blood pressure measurements in the extremity with a hemodialysis access device. This is commonly communicated to all caregivers by placing an alert bracelet on the arm that needs to be protected. This alert bracelet prompts the primary health care provider to investigate the need for the bracelet. The use of an alert wrist bracelet (rather than a visibly posted note or sign) also maintains client confidentiality. Agency procedure is always followed. An allergy bracelet is placed on the client with an allergy. Placing a note on the front of the medical record does not ensure that everyone caring for the client is aware of the access device. The client should not be responsible for informing the caregivers.