# A nurse is caring for a client with an arteriovenous (AV) fistula in the right forearm for hemodialysis access. Which nursing intervention 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=541413 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a client with an arteriovenous (AV) fistula in the right forearm for hemodialysis access. Which nursing intervention 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 sign monitoring 2. Encourage the client to sleep on the left side to promote circulation 3. Perform venipuncture on the left arm for routine blood draws 4. Assess for the presence of a thrill and bruit in the AV fistula **✔ 정답** **정답: 4** ## 해설 Regular assessment of thrill and bruit is critical to monitor fistula patency and detect complications early. Other interventions (BP cuff, venipuncture, sleeping on side) can damage the fistula and are contraindicated. ## 심화 해설 Understanding the Priority: AV Fistula Patency and Safety The most critical nursing intervention for maintaining an arteriovenous (AV) fistula is the routine assessment of its function through palpation for a thrill and auscultation for a bruit. An AV fistula is created by surgically anastomosing an artery directly to a vein, which allows high-pressure arterial blood flow to engorge and thicken the venous wall over a period of weeks to months—a process known as maturation. The thrill is a continuous, palpable buzzing sensation felt over the fistula, and the bruit is the audible whooshing sound heard with a stethoscope. These are normal, expected findings that signify turbulent, high-velocity blood flow through a patent vascular access [3]. The rationale for making this assessment the highest priority lies in the concept of early detection of access failure. The primary threat to fistula longevity is thrombosis. A meticulous physical assessment, which includes checking for the thrill and bruit, is the frontline surveillance method for identifying a failing or recently thrombosed access [4]. A change in the character of the bruit (from a continuous, low-pitched sound to a high-pitched, discontinuous systolic-only sound) or a loss of the thrill are early indicators of stenosis, a narrowing within the vessel that reduces flow and precedes complete thrombosis [3]. Evidence-based protocols emphasize that nurses must be proficient in this physical assessment to promptly recognize and escalate findings of a "threatened access," as a thrombosed fistula requires urgent intervention to restore patency and avoid unplanned hospital admissions [2]. While proper cannulation technique is a major factor in long-term patency, the immediate, shift-by-shift assessment for thrill and bruit is the cornerstone of safety monitoring . Analysis of Incorrect Options The other options, while representing important principles of fistula care, are not the most important intervention for maintaining patency and safety in the context of ongoing monitoring. - Option 1: Applying a blood pressure cuff to the left arm is a correct protective measure, but it is a passive intervention to prevent injury, not an active assessment to detect a current problem. The overarching principle is to avoid any compression of the fistula limb that could reduce blood flow and precipitate stasis and clotting. This includes blood pressure cuffs, tight clothing, and jewelry on the access arm [4]. - Option 2: Encouraging the client to sleep on the left side is another protective measure to avoid external compression of the right arm fistula from the patient's own body weight. Like Option 1, this prevents a potential cause of thrombosis but does not provide information about the fistula's current functional status. - Option 3: Performing venipuncture on the left arm is a standard precaution to preserve the vasculature of the access arm exclusively for dialysis. Venipuncture in the fistula arm can cause trauma, infiltration, and infection, damaging the lifeline for hemodialysis. This is a long-term preservation strategy, not an immediate safety and patency check [4]. Therefore, while all options describe correct care principles, only the assessment for a thrill and bruit provides the real-time data necessary to confirm that the fistula is currently functioning and safe to use, making it the highest priority nursing intervention.References (research sources) - [2]Improving assessment and escalation of threatened haemodialysis access: results of a nursing-led program.Research articleForcey D, Tran D, Connor J, Ayudhya PKN, Ocampo C, Nelson C, Crikis S. (2023) · DOI: 10.1186/s12882-023-03321-z - [3]Monitoring the Patient Following Radio-Cephalic Arteriovenous Fistula Creation: Current Perspectives.Research articlePirozzi N, Mancianti N, Scrivano J, Fazzari L, Pirozzi R, Tozzi M. (2021) · DOI: 10.2147/vhrm.s205130 - [4]Overview of hemodialysis access and assessment.Research articleArasu R, Jegatheesan D, Sivakumaran Y. (2022) · DOI: 10.46747/cfp.6808577 ## 임상 시나리오 AV Fistula AssessmentThrill & Bruit Surveillance for Patency Assess the fistula every shift and before each dialysis session by palpating for a continuous thrill and auscultating for a low-pitched, continuous bruit. A change from a continuous to a discontinuous, systolic-only bruit or a loss of thrill signals stenosis, a precursor to thrombosis. Report these changes immediately. CautionNever take blood pressure, perform venipuncture, or apply any constrictive devices on the access extremity. Place an identification bracelet or label on the limb to alert all staff. ## 핵심 개념 - **Thrill** — A continuous palpable buzzing sensation felt over a patent AV fistula, indicating turbulent blood flow. - **Bruit** — An audible whooshing sound heard on auscultation over a patent AV fistula, signifying high-velocity blood flow. - **AV Fistula Thrombosis** — Clot formation within the vascular access, the primary threat to fistula longevity, often preceded by stenosis. - **Stenosis** — Narrowing of the vessel lumen in an AV fistula, which reduces blood flow and is an early indicator of impending access failure. - **Fistula Maturation** — The postoperative process where high-pressure arterial flow engorges and thickens the venous wall, making it suitable for repeated cannulation. ## 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 a mature arteriovenous (AV) fistula in the right forea…](https://mymerci.kr/pages/nclex_q.php?qn_id=541411) - [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 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._