# 血液透析前，護理師無法在個案的動靜脈瘻管上觸及震顫或聽到嘈音。護理師應採取下列何項措施？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=497916&lang=zh-tw  
> language: zh-TW  
> subject: Postsurgical Complications  
> category: ROR

## 題目

血液透析前，護理師無法在個案的動靜脈瘻管上觸及震顫或聽到嘈音。護理師應採取下列何項措施？

## 選項

1. 將血壓壓脈帶綁在瘻管手臂上，並比較雙臂
2. 用力按摩瘻管，直到容易感覺到震動
3. 繼續進行穿刺，並在透析開始後重新評估血管通路
4. 停止使用血管通路，並通知透析團隊可能有阻塞 **✔ 正確答案**

**正確答案: 4**

## 解析

震顫和嘈音消失表示血流可能因狹窄或血栓而中斷。不應進行穿刺；護理師應保護手臂並立即通知透析團隊，以便評估和恢復通暢性。

## 深入解析

快速解答
不要使用瘻管，並立即通知透析團隊。震顫和嘈音消失表示血流可能嚴重減少或消失。

為什麼這是正確的
功能正常的瘻管會產生可觸及的震動和可聽見的血流聲。兩者消失可能表示血栓或嚴重阻塞，此時插入針頭可能損傷血管通路或無法提供足夠的透析，同時延誤了時效性的評估。

簡單比喻或心智圖像
震顫和嘈音就像水流過水管時的震動和聲音。當兩者都消失時，應檢查是否有阻塞，而不是刺穿水管；此比喻無法在沒有臨床評估的情況下確定確切的病灶。

記憶掛鉤
無震顫、無嘈音，就不可使用血管通路：保護手臂，立即通報可能的阻塞。

NCLEX 決策規則
使用前透過看、聽、觸來評估血液透析血管通路。若血流徵象消失或明顯改變，應避免穿刺和對手臂加壓，並通知透析團隊進行緊急評估。

為什麼其他選項是錯的
血壓壓脈帶會對瘻管手臂造成壓迫。用力按摩可能損傷已受損的瘻管，而繼續穿刺則有浸潤、血管通路損傷和透析無效的風險。參考文獻

- [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing

- [2]National Kidney Foundation: Hemodialysis AccessNational Kidney Foundation

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