Practice Question
A 62-year-old client with ESKD returns from surgery with a newly revised right upper-extremity AV shunt. Which nursing action best protects the patency and integrity of the access site?
Answer Choices:
Correct Answer:
Place a sign on the patient's door that reads, "No lab draws, IVs, or BP to right arm."
Rationale:
✅ A new AV access is at high risk for thrombosis, bleeding, and trauma, so the priority is preventing anything that compresses or injures the site.
✅ Blood pressure cuffs can occlude blood flow, increasing risk of clotting and loss of access patency.
✅ IV starts and lab draws can cause vessel damage or infection risk in the access arm, threatening long-term dialysis use.
✅ Clear signage protects the access by alerting all staff across shifts, preventing accidental use of the arm.
✅ This intervention is a high-impact nursing safeguard that preserves patency and integrity of the newly revised shunt.
Auscultate for the thrill and feel for the bruit…
✅ The correct assessment is feel for thrill and auscultate for bruit, but the option reverses them, making it inaccurate.
✅ Also, assessment is important, but preventing compression/trauma is the best action to protect patency.
Measure BP in both right and left arms…
✅ Measuring BP on the access arm risks compressing the shunt and causing clot formation.
✅ BP should be taken on the non-access arm unless contraindicated.
Apply a snug compression wrap and elevate the right arm above heart level.
✅ A snug wrap can reduce blood flow and increase thrombosis risk in the access.
✅ Elevation may help swelling, but compression that threatens flow is unsafe for a fresh access.
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This question is from Custom NURS2201 Final Exam 2025 – LFT which contains 74 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN Custom Exam(s)
- Answer Choices: 4