# A client has a newly created arteriovenous fistula in the right forearm. For each group, select all responses that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=620060&lang=en  
> language: en  
> subject: Postsurgical Complications  
> category: ROR

## Question

A client has a newly created arteriovenous fistula in the right forearm. For each group, select all responses that apply.

Protecting the access arm

Avoid blood pressure measurement on the access arm

Wear a tight compression sleeve over the fistula

Avoid venipuncture and IV insertion in the access arm

Sleep with body weight resting on the access arm

Assessing patency

Palpate the fistula for a thrill each day

Auscultate the fistula for a bruit each day

Wait until the next dialysis treatment to report an absent thrill or bruit

Apply firm pressure over a weak thrill to improve blood flow

## Explanation

Protect the access arm from compression, blood pressure measurement, venipuncture, and IV insertion. Patency is assessed by regularly palpating the thrill and auscultating the bruit. The absence of either finding requires prompt reporting; it should not be ignored until dialysis. Tight clothing, sleeping on the arm, or applying pressure or heat without an order can impair or injure the access.

## In-depth explanation

Quick answer
Protect the access arm from compression, blood pressure measurement, venipuncture, and IV insertion. Patency is assessed by regularly palpating the thrill and auscultating the bruit. The absence of either finding requires prompt reporting; it should not be ignored until dialysis. Tight clothing, sleeping on the arm, or applying pressure or heat without an order can impair or injure the access.
Key cues
Use only the findings, timing, and orders stated in the scenario.
Clinical reasoning
Apply the requested nursing decision to this client rather than relying on a broad disease label.
Why the alternatives do not fit
The remaining responses are contradicted by the scenario, mistimed, outside scope, or unsafe.
Priority and safety
Address immediate threats first and reassess after intervention.
Takeaway
Choose only actions supported at this exact point in care.
**Sources**
- Open RN Nursing Skills 2e

## Clinical scenario

A client has a newly created arteriovenous fistula in the right forearm. For each group, select all responses that apply.

## Key concepts

- **arteriovenous fistula** — arteriovenous fistula is a key clinical concept for assessing and managing hemodialysis access protection.
- **thrill** — thrill is a key clinical concept for assessing and managing hemodialysis access protection.
- **bruit** — bruit is a key clinical concept for assessing and managing hemodialysis access protection.

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