# A nurse is caring for a client with a mature arteriovenous (AV) fistula in the right forearm for hemodialysis access. Which nursing action is most important to maintain the patency and safety of the AV fistula? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541411 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a client with a mature arteriovenous (AV) fistula in the right forearm for hemodialysis access. Which nursing action is most important to maintain the patency and safety of the AV fistula? ## 보기 1. Apply a blood pressure cuff to the left arm for routine vital signs 2. Encourage the client to sleep on the left side to promote circulation 3. Palpate for thrill and auscultate for bruit during each assessment **✔ 정답** 4. Perform venipuncture in the left arm for laboratory blood draws **정답: 3** ## 해설 Regular assessment of thrill and bruit is the priority to monitor AV fistula patency and detect complications early. Other options involve harmful procedures or are not evidence-based for safety. ## 심화 해설 Understanding the AV Fistula as a Lifeline An arteriovenous (AV) fistula is a surgically created connection between an artery and a vein, most often in the arm, to provide vascular access for hemodialysis. Once it matures, the high-pressure arterial blood flow causes the vein to enlarge and its walls to thicken, a process known as maturation. This matured vessel is the patient's "lifeline" for dialysis, as it allows for the high blood flow rates needed to effectively filter the blood . The primary nursing responsibility is to protect this lifeline and ensure it remains functional and free from complications like clotting (thrombosis) or infection. Analyzing the Priority Nursing Action The most important action to maintain patency and safety is to palpate for a thrill and auscultate for a bruit during each assessment. - A thrill is a continuous, buzzing sensation felt over the fistula, similar to a cat's purr, caused by the turbulent, high-pressure blood flow from the artery directly into the vein. - A bruit (pronounced "broo-ee") is the whooshing sound heard with a stethoscope over the same area, which corresponds to the same turbulent flow. These two assessments are the most direct, non-invasive indicators of fistula patency. The presence of a strong thrill and a loud, continuous bruit confirms that blood is flowing freely through the access. A change in the character of the bruit (becoming high-pitched or discontinuous) or a loss of the thrill is a critical early warning sign of stenosis (narrowing) or thrombosis (clotting), requiring immediate intervention to save the access [1, 3]. This makes this assessment the cornerstone of vascular access monitoring and the highest priority for maintaining fistula function. Why Other Options Are Incorrect and Dangerous - Option 1: Applying a blood pressure cuff to the left arm. While it is a correct principle to avoid the fistula arm, the question asks for the *most important* action to maintain the fistula itself. Using the opposite arm for blood pressure is a protective measure, not an active assessment of the fistula's function. More critically, any form of compression, including a blood pressure cuff, a tourniquet, or tight clothing, must be strictly avoided on the extremity with the AV fistula. Compression can lead to stasis of blood flow and rapidly cause thrombosis, destroying the lifeline . - Option 2: Encouraging the client to sleep on the left side. This is a protective measure to avoid compressing the right arm fistula. However, it is not an assessment and does not provide any information about the fistula's current patency or function. While important for patient education, it does not take priority over a direct functional assessment. - Option 4: Performing venipuncture in the left arm for blood draws. This is another crucial protective strategy. The veins in the extremity with the AV fistula are reserved exclusively for hemodialysis cannulation. Using them for routine venipuncture can damage the vessel, cause infiltration, and lead to infection or thrombosis, compromising the access site [1, 2]. However, like the other incorrect options, this is a protective action performed on the *opposite* arm and does not involve a direct evaluation of the fistula's status, making it a lower priority than the immediate, hands-on assessment of thrill and bruit. The preservation of a complication-free AV fistula is a significant challenge, and consistent, standardized assessment by nurses is critical to identifying problems early [1, 2]. The immediate assessment of thrill and bruit provides real-time data on the fistula's patency, making it the most important and time-sensitive nursing action among the choices provided. ## 임상 시나리오 AV Fistula AssessmentPatency Check at the Bedside Assess the fistula every shift and before each dialysis session. Palpate for a continuous thrill and auscultate for a low-pitched, continuous bruit. A change to a high-pitched, discontinuous bruit or a loss of thrill suggests stenosis or thrombosis. Report immediately. CautionNever take blood pressure, perform venipuncture, or place restrictive devices on the access arm. Palpate gently to avoid occluding flow. ## 핵심 개념 - **Thrill** — A continuous buzzing sensation palpated over a patent AV fistula, indicating turbulent blood flow. - **Bruit** — A whooshing sound auscultated over a patent AV fistula, corresponding to turbulent blood flow. - **AV Fistula** — A surgically created connection between an artery and a vein for hemodialysis vascular access. ## 같은 주제 문제 - [A nurse is caring for a client with a newly created arteriovenous (AV) fistula in the left…](https://mymerci.kr/pages/nclex_q.php?qn_id=541409) - [A nurse is caring for a client with a newly created arteriovenous (AV) fistula in the left…](https://mymerci.kr/pages/nclex_q.php?qn_id=541410) - [A nurse is caring for a client with an arteriovenous (AV) fistula in the left arm for hemo…](https://mymerci.kr/pages/nclex_q.php?qn_id=541412) - [A nurse is caring for a client with an arteriovenous (AV) fistula in the right forearm for…](https://mymerci.kr/pages/nclex_q.php?qn_id=541413) - [A nurse is assessing a patient with an arteriovenous (AV) fistula in the left upper arm cr…](https://mymerci.kr/pages/nclex_q.php?qn_id=541414) - [A nurse is assessing a patient with an arteriovenous (AV) fistula in the left forearm crea…](https://mymerci.kr/pages/nclex_q.php?qn_id=541415) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._