A patient has an arteriovenous fistula in the left arm for haemodialysis. Where should the nurse measure the blood pressure?
Correct answer: C. On the right arm if it is clinically suitable
- A. On the left arm below the fistula
- B. On the left arm over the fistula
- C. On the right arm if it is clinically suitable
- D. On either arm after applying extra cuff pressure
Explanation
Blood pressure is measured on the opposite arm when an arteriovenous fistula is present. Compression of the access arm can damage the fistula or reduce blood flow, so the access arm should not be used unless specifically directed.
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About Vital Signs and Monitoring
Vital signs include temperature, pulse, respiration, blood pressure, oxygen saturation and pain assessment. Coverage includes correct measurement sites and techniques, normal adult ranges, factors that alter readings, trends in patient observations, and the difference between an abnormal finding that needs reassessment and one requiring immediate reporting.
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