# Situation: A 30-year-old woman with systemic lupus erythematosus (SLE) and lupus nephritis has end-stage kidney disease and receives hemodialysis three times a week through an arteriovenous fistula in her left forearm. She still passes a small amount of urine each day. Her skin rash is currently inactive. The nurse teaches her how to care for her arteriovenous fistula at home. Which instruction should the nurse give?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629950  
> language: ko  
> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 30-year-old woman with systemic lupus erythematosus (SLE) and lupus nephritis has end-stage kidney disease and receives hemodialysis three times a week through an arteriovenous fistula in her left forearm. She still passes a small amount of urine each day. Her skin rash is currently inactive.

The nurse teaches her how to care for her arteriovenous fistula at home. Which instruction should the nurse give?

## 보기

1. Avoid touching the fistula site so that it does not get infected
2. Have blood samples drawn from the fistula arm to spare her veins
3. Carry her shopping bags on the fistula arm to strengthen it
4. Feel for the buzzing thrill over the fistula every day **✔ 정답**

**정답: 4**

## 해설

A palpable thrill (a buzzing vibration) means blood is flowing through the fistula; its absence suggests clotting and must be reported at once. The access arm is protected: no blood pressure cuffs, blood draws, tight sleeves, or heavy bags on that arm. Keeping the site clean prevents infection, but the client still touches it daily to check the thrill.

## 심화 해설

Understanding the AV fistula as a lifeline
A mature arteriovenous fistula is created by surgically connecting an artery directly to a vein in the forearm. The high-pressure arterial flow continuously surges into the low-pressure vein, causing the vein to enlarge and its wall to thicken. This remodeling produces two classic bedside findings: a palpable thrill (a continuous buzzing vibration felt over the fistula) and an audible bruit (a swishing sound heard with a stethoscope). Both findings reflect turbulent, high-volume blood flow through the access. When the fistula develops thrombosis or critical stenosis, flow drops abruptly, and the thrill disappears. Because a clotted fistula can often be salvaged only if intervention occurs within hours, daily detection of flow loss is a core self-care behavior for every patient on hemodialysis .

Why daily thrill checks are the correct instruction
Feeling for the buzzing thrill every day is the most direct way for the patient to confirm that blood is still moving through the fistula. The patient should place the flat palm or fingers lightly over the fistula site, usually near the anastomosis and along the outflow vein, and note whether the vibration is present and whether its intensity has changed. A sudden absence of the thrill, or a thrill that becomes markedly weaker, is a warning sign of impending or established thrombosis and must be reported to the dialysis unit or vascular access team immediately . This instruction is safe, requires no equipment, and can be performed at home between dialysis sessions. Key point! The patient is not being asked to avoid touching the fistula; rather, touching it daily for assessment is an essential protective behavior.

Why the other options are incorrect
Option 1 reflects a misunderstanding of infection prevention. Keeping the fistula site clean is important, but cleanliness does not mean avoiding all contact. The patient should wash hands before palpating the fistula and keep the skin over the access clean and dry. Avoiding touch entirely would prevent the daily thrill assessment that detects early clotting .

Option 2 is dangerous. The fistula arm must be protected from all unnecessary needle sticks. Blood draws, intravenous lines, and blood pressure cuffs on the access arm can damage the vessel, cause hematoma, or contribute to thrombosis and stenosis. Blood samples should be drawn from the opposite arm or from the dialysis circuit during treatment, not from the fistula arm .

Option 3 is also harmful. Carrying shopping bags or any heavy load on the fistula arm compresses the vessel and raises venous pressure, which can reduce flow and promote clotting. The access arm should be kept free of tight sleeves, watches, heavy bags, and sustained pressure .

| Home care action | Correct or incorrect | Rationale |
| --- | --- | --- |
| Feel for the thrill daily | Correct | Confirms blood flow; absence suggests clotting and requires urgent reporting |
| Avoid touching the fistula site | Incorrect | Prevents the daily flow check; clean hands before palpation are sufficient |
| Allow blood draws from the fistula arm | Incorrect | Needle injury and pressure can damage the access and promote thrombosis |
| Carry heavy bags on the fistula arm | Incorrect | Compression reduces flow and increases clotting risk |

Integrating self-care education into practice
Structured education improves multiple self-care behaviors in patients with an arteriovenous fistula. In a pre-post study, patients who received fistula education showed significant gains in self-care behavior scores compared with baseline . A randomized controlled trial using an educational video also demonstrated improvements in knowledge, attitude, and practice related to fistula self-care at seven and fourteen days after the intervention . These findings support teaching patients not only to check the thrill daily but also to keep the access arm free of constriction, avoid blood pressure measurement and venipuncture on that arm, and report signs such as redness, swelling, pain, or loss of the thrill promptly .

For this patient, the single most important home instruction is to feel for the buzzing thrill over the fistula every day and to report any change immediately. The presence of a thrill is a direct, real-time indicator of fistula patency, and its loss is the earliest warning that the lifeline for hemodialysis may be failing.

## 임상 시나리오

AV Fistula Home CareDaily thrill check is the priority self-monitoring
Teach the patient to feel for the buzzing thrill over the fistula every day. A palpable thrill means blood is flowing; its sudden absence or marked weakening suggests thrombosis and requires immediate reporting to the dialysis unit.

Protect the access arm: no blood pressure cuffs, no blood draws, no tight sleeves, and no heavy bags on that arm. These actions can compress or injure the fistula and reduce blood flow.

CautionKeeping the site clean prevents infection, but the patient must still touch the fistula daily to check the thrill. A clotted fistula is often salvageable only if intervention occurs within hours.

## 핵심 개념

- **Thrill** — A palpable buzzing vibration felt over a functioning arteriovenous fistula, indicating turbulent blood flow through the access.
- **Bruit** — An audible swishing sound heard with a stethoscope over a functioning fistula, reflecting high-volume blood flow.
- **Arteriovenous fistula** — A surgical connection between an artery and a vein, usually in the forearm, created to provide long-term vascular access for hemodialysis.
- **Thrombosis** — Formation of a blood clot within the fistula, which can obstruct blood flow and cause loss of the thrill and bruit.
- **Vascular access** — The site through which blood is removed and returned during hemodialysis; a functioning access is essential for adequate dialysis.

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