# 個案右前臂有一新建立的動靜脈瘻管。針對每組，請選出所有適用的選項。

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

## 題目

個案右前臂有一新建立的動靜脈瘻管。針對每組，請選出所有適用的選項。

保護瘻管手臂

避免在瘻管手臂測量血壓

在瘻管上穿戴緊身壓力袖套

避免在瘻管手臂進行靜脈穿刺與靜脈注射插入

睡覺時將身體重量壓在瘻管手臂上

評估通暢性

每天觸診瘻管是否有震顫

每天聽診瘻管是否有雜音

等到下次透析治療時才報告震顫或雜音消失

在微弱的震顫上施加穩固壓力以改善血流

## 解析

應保護瘻管手臂免受壓迫、血壓測量、靜脈穿刺及靜脈注射插入。通暢性是藉由定期觸診震顫及聽診雜音來評估。若其中任一徵象消失，需立即報告；不應等到透析時才處理。穿著緊身衣物、睡覺時壓在手臂上，或無醫囑而施加壓力或熱敷，都可能損害或傷害瘻管。

## 深入解析

快速解答
應保護瘻管手臂免受壓迫、血壓測量、靜脈穿刺及靜脈注射插入。通暢性是藉由定期觸診震顫及聽診雜音來評估。若其中任一徵象消失，需立即報告；不應等到透析時才處理。穿著緊身衣物、睡覺時壓在手臂上，或無醫囑而施加壓力或熱敷，都可能損害或傷害瘻管。
關鍵線索
僅使用情境中所述的發現、時間點與醫囑。
臨床推理
將所要求的護理決策應用於此個案，而非仰賴廣泛的疾病標籤。
為何其他選項不適用
其餘選項與情境矛盾、時間點不當、超出範圍或不安全。
優先順序與安全
先處理立即性威脅，並在介入後重新評估。
重點提示
僅選擇在此次照護時間點上受到支持的行動。
**參考資料**
- Open RN Nursing Skills 2e

## 臨床情境

個案右前臂有一新建立的動靜脈瘻管。針對每組，請選出所有適用的選項。

## 重要概念

- **arteriovenous fistula** — 動靜脈瘻管是評估與處理血液透析瘻管保護的關鍵臨床概念。
- **thrill** — 震顫是評估與處理血液透析瘻管保護的關鍵臨床概念。
- **bruit** — 雜音是評估與處理血液透析瘻管保護的關鍵臨床概念。

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