# A patient with end-stage renal disease is post-op day 1 from a left forearm arteriovenous (AV) fistula creation for future hemodialysis access. Which nursing assessments and interventions are appropriate? Select all that apply.

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=373261&lang=en  
> language: en  
> subject: Reduction of Risk Potential  
> category: ROR

## Question

A patient with end-stage renal disease is post-op day 1 from a left forearm arteriovenous (AV) fistula creation for future hemodialysis access. Which nursing assessments and interventions are appropriate? Select all that apply.

1

Auscultate for a bruit and palpate for a thrill over the fistula every shift and as needed; absence of either suggests fistula thrombosis and requires immediate provider notification.

2

Encourage hand-grip exercises (for example, squeezing a soft ball) starting 1 to 2 weeks after surgery to promote fistula maturation.

3

Place a "no BP, no venipuncture, no IV" sign over the bed for the affected extremity, alert all staff, and band the patient.

4

Assess for signs of steal syndrome — distal extremity pallor, coolness, pain, paresthesia, or weak pulse — and notify the provider immediately if present.

5

Elevate the affected arm on two pillows and apply a snug circumferential dressing every 8 hours to minimize edema and protect the fistula site from infection.

## Explanation

AV fistula post-op care: assess for bruit (auscultate) and thrill (palpate) every shift — both are required for patency and absence indicates thrombosis; protect the limb (no BP/venipuncture/IV with signage and patient banding); encourage hand-grip exercises after the initial healing period to promote maturation; assess for steal syndrome (distal ischemia from arterial flow diversion). Choice 5 is wrong — a TIGHT circumferential dressing would compress the fistula and cause thrombosis; loose, non-compressive coverings are appropriate.

## In-depth explanation

The fistula limb gets a "DO NOT" sign — no blood pressure, no venipuncture, no IV. Lifelong rule. Bruit + thrill = patent. Loss of either = STAT call. Steal syndrome (distal ischemia) is the second most-tested fistula complication after thrombosis.

## Clinical scenario

**End-stage renal disease patient, post-op day 1** after **left forearm AV fistula creation**. The fistula is not yet matured for cannulation — projected use in 8 to 12 weeks.

## Key concepts

- **AV fistula** — Surgically created direct connection between an artery and vein for long-term hemodialysis access; matures over 8-12 weeks.
- **Thrill / bruit** — Palpable vibration (thrill) and audible whooshing (bruit) over a patent fistula; absence indicates thrombosis.
- **Steal syndrome** — Distal limb ischemia from arterial flow diversion through the fistula; presents with pallor, coolness, pain, paresthesia.

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