Buttonhole Cannulation – What Do We Know? (MCQs)
1. What is Buttonhole Cannulation?
A. A technique for peritoneal dialysis
B. A method for repeated cannulation at the same site in AV fistula
C. A type of vascular access surgery
D. A dialysis catheter placement method
✅ Correct answer: B
2. What is formed at the cannulation site during Buttonhole technique?
A. Thrombosis
B. Hematoma
C. Scar tissue
D. Epithelialized track (tunnel)
✅ Correct answer: D
3. What type of needle is used for cannulation in a mature Buttonhole track?
A. Blunt needle
B. Sharp needle
C. Butterfly needle
D. Central venous catheter
✅ Correct answer: A
4. Which of the following is an advantage of the Buttonhole technique?
A. Higher infection rate
B. Reduced pain during cannulation
C. Increased bleeding
D. Greater use of sharp needles
✅ Correct answer: B
5. During the track creation phase of Buttonhole cannulation, which type of needle is used?
A. Blunt needle
B. Catheter needle
C. Sharp needle
D. Arterial needle
✅ Correct answer: C
6. Which of the following patients is most suitable for Buttonhole technique?
A. Patients with AV graft
B. Patients with central line
C. Patients with newly created fistula
D. Patients with matured AV fistula with limited cannulation sites
✅ Correct answer: D
7. What is a key requirement to maintain a Buttonhole track?
A. Use different cannulators every time
B. Cannulate at random angles
C. Use of the same angle and depth consistently
D. Cannulate at a different site daily
✅ Correct answer: C
8. A potential complication of Buttonhole cannulation is:
A. Pneumothorax
B. Peritonitis
C. Localized infection or abscess
D. Cardiac tamponade
✅ Correct answer: C
9. Why is scab removal important before Buttonhole cannulation?
A. To reduce bleeding
B. To reduce infection risk and allow proper needle insertion
C. To promote scar formation
D. To avoid using blunt needles
✅ Correct answer: B
10. How often should the initial track (tunnel) be cannulated by the same person ideally?
A. Once only
B. By different staff for experience
C. By the same cannulator to maintain consistency
D. Randomly to avoid favoritism
✅ Correct answer: C
11. How many successful cannulations using a sharp needle are typically required to form a mature Buttonhole track?
A. 1–2 times
B. 3–5 times
C. 6–10 times
D. 15 times
✅ Correct answer: C
12. In Buttonhole cannulation, a key technique is to:
A. Rotate the needle to widen the tunnel
B. Insert the needle at a different angle each time
C. Maintain the same angle, direction, and depth
D. Use higher pressure to insert the needle faster
✅ Correct answer: C
13. The Buttonhole technique is NOT recommended in which of the following access types?
A. AV fistula
B. AV graft
C. Radiocephalic fistula
D. Brachiocephalic fistula
✅ Correct answer: B
14. Which factor is associated with a higher risk of infection in Buttonhole cannulation?
A. Daily use of antiseptic
B. Improper scab removal
C. Use of blunt needles
D. Rotating cannulation sites
✅ Correct answer: B
15. What is one of the most critical infection control practices before Buttonhole cannulation?
A. Soaking needles in alcohol
B. Applying a warm compress
C. Removing the scab using a sterile technique
D. Wiping with tissue paper
✅ Correct answer: C
16. Which of the following is a contraindication for Buttonhole technique?
A. Patient prefers self-cannulation
B. AV graft use
C. Mature fistula with limited sites
D. Stable AV fistula in use for over 6 months
✅ Correct answer: B
17. Which personnel are best to perform the initial Buttonhole track formation?
A. New trainees
B. Any rotating staff
C. Consistent, trained staff members
D. Patient only
✅ Correct answer: C
18. Which is a common misconception about Buttonhole technique?
A. It reduces pain
B. It decreases aneurysm formation
C. It increases needle dislodgement risk
D. It is suitable for all access types
✅ Correct answer: D
19. When cannulating a mature Buttonhole track, resistance is usually felt when:
A. The needle hits a valve
B. The needle is inserted too deep
C. The scab is not removed
D. The angle or direction is incorrect
✅ Correct answer: D
20. What is the primary goal of the Buttonhole technique in long-term dialysis patients?
A. Promote graft use
B. Reduce cost
C. Preserve access longevity and reduce trauma
D. Increase blood flow
✅ Correct answer: C
21. A patient using Buttonhole cannulation reports pain and swelling at the site. What should you suspect?
A. Proper cannulation
B. Track maturity
C. Local infection or abscess
D. Dehydration
✅ Correct answer: C
22. Which of the following is not a benefit of Buttonhole cannulation?
A. Easier self-cannulation
B. Reduced aneurysm formation
C. Reduced risk of local infection
D. Decreased infiltration
✅ Correct answer: C
23. One disadvantage of the Buttonhole technique is:
A. Inability to reuse needles
B. Increased rate of hematoma
C. Higher risk of infection if hygiene is poor
D. Need for general anesthesia
✅ Correct answer: C
24. What should be done immediately before cannulation with blunt needles in Buttonhole?
A. Massage the fistula
B. Apply alcohol swab only
C. Remove scab using sterile forceps or pick
D. Use heparin lock
✅ Correct answer: C
25. Why is consistent staff assignment important in Buttonhole cannulation?
A. Reduces salary cost
B. Ensures correct use of different tracks
C. Maintains consistency in angle, depth, and site
D. Avoids patient complaints
✅ Correct answer: C
26. During the healing phase of a Buttonhole track, what should NOT be done?
A. Keep using sharp needles
B. Allow the track to rest for a few days
C. Use blunt needles
D. Reinsert at the exact site and angle
✅ Correct answer: C
27. What is the minimum number of successful cannulations usually required to create a usable Buttonhole tunnel?
A. 2
B. 5
C. 6–10
D. 12–15
✅ Correct answer: C
28. Which of the following is true regarding blunt needles?
A. They are used to create new tunnels
B. They have a higher risk of infiltration
C. They are used only after tunnel formation
D. They are used in AV grafts
✅ Correct answer: C
29. Which infection prevention strategy is most critical with Buttonhole cannulation?
A. Rotating cannulation sites
B. Using antibiotics after dialysis
C. Strict aseptic technique and scab removal
D. Using only new gloves per shift
✅ Correct answer: C
30. Which patient education point is most essential for self-cannulating using Buttonhole technique?
A. Use new site every time
B. Use sharp needles always
C. Use same angle and depth every time
D. Alternate arms every week
✅ Correct answer: C
31. Which of the following is used to clean the Buttonhole site before scab removal?
A. Sterile water
B. Alcohol swab
C. Normal saline
D. Betadine or antiseptic solution (e.g., chlorhexidine)
✅ Correct answer: D
32. What is the risk if a non-mature track is cannulated with a blunt needle?
A. Aneurysm formation
B. Successful track formation
C. Bleeding and infiltration
D. Reduced infection risk
✅ Correct answer: C
33. During cannulation, you notice resistance at the usual angle. What is the correct action?
A. Apply force to insert the needle
B. Use a sharp needle to force entry
C. Withdraw and reassess angle and site
D. Push deeper
✅ Correct answer: C
34. How should scabs at the Buttonhole site be removed?
A. With gloved fingers
B. With sterile tweezers or pick under aseptic technique
C. With gauze soaked in alcohol
D. With water pressure
✅ Correct answer: B
35. Which of the following can help minimize pain during cannulation?
A. Using a larger gauge needle
B. Changing site frequently
C. Application of topical anesthetic (e.g., EMLA cream)
D. Using non-sterile gloves
✅ Correct answer: C
36. Which patient behavior increases risk of Buttonhole site infection?
A. Adherence to hand hygiene
B. Consistent cannulation technique
C. Touching scab or site with bare hands
D. Daily use of antiseptic
✅ Correct answer: C
37. What is the appropriate gauge size of blunt needles typically used for mature Buttonhole tracks?
A. 14G
B. 15G
C. 16G or 17G
D. 20G
✅ Correct answer: C
38. What should be done if a Buttonhole site becomes infected?
A. Continue using the same site
B. Skip dialysis
C. Stop using the site, start antibiotics, consider new site
D. Increase dialysate flow
✅ Correct answer: C
39. Buttonhole cannulation should ideally be done by:
A. Trainee staff only
B. The same few experienced cannulators
C. A different person daily
D. Patient relatives
✅ Correct answer: B
40. Why should cannulation be done at exact same angle each time in Buttonhole technique?
A. To make the tunnel wider
B. To reduce infection
C. To maintain the epithelial track and prevent trauma
D. To reduce the number of needles used
✅ Correct answer: C
41. Which of the following best describes the main difference between Buttonhole and rope-ladder cannulation techniques?
A. Buttonhole uses rotating sites; rope-ladder uses same site
B. Rope-ladder uses sharp needles only
C. Buttonhole uses same site, angle, and depth every time
D. Rope-ladder has higher infection risk
✅ Correct answer: C
42. The Buttonhole technique can help reduce which of the following complications?
A. Central line infections
B. Hemodialysis catheter blockage
C. Aneurysm and pseudoaneurysm formation in fistula
D. Hypertension
✅ Correct answer: C
43. What is the correct management if bleeding continues longer than usual after removing needles from Buttonhole site?
A. Re-cannulate immediately
B. Apply light pressure only
C. Apply firm pressure and monitor bleeding time
D. Leave site open
✅ Correct answer: C
44. Which of the following is true about epithelialization of Buttonhole tracks?
A. It refers to muscle thickening
B. It makes the tunnel softer
C. It forms a stable, scar-lined path for the needle
D. It prevents fistula maturation
✅ Correct answer: C
45. What does increased resistance or pain during blunt needle insertion into a Buttonhole site most likely indicate?
A. The tunnel is clear
B. A sharp needle is needed
C. Improper alignment with the track
D. The patient has low blood pressure
✅ Correct answer: C
46. If a Buttonhole site becomes too inflamed or infected, what is the next best step?
A. Ignore and proceed with cannulation
B. Switch to rope-ladder at same site
C. Stop using the site, allow healing, monitor and treat
D. Use a central venous catheter immediately
✅ Correct answer: C
47. Which of the following materials is preferred for scab removal before Buttonhole cannulation?
A. Cotton ball
B. Non-sterile gauze
C. Sterile pick or sterile forceps
D. Alcohol-soaked paper towel
✅ Correct answer: C
48. One reason some centers are cautious about using Buttonhole technique is:
A. Requires less staff
B. Lower blood flow rates
C. Risk of increased bloodstream infection if protocol is not followed
D. It’s more painful than sharp-needle cannulation
✅ Correct answer: C
49. How can facilities reduce infection rates in Buttonhole cannulation?
A. Avoid blunt needles
B. Switch to AV graft
C. Use strict antiseptic protocol, hand hygiene, and limit staff handling
D. Use warm compress before every dialysis
✅ Correct answer: C
50. What is the purpose of marking the Buttonhole site on the skin?
A. Cosmetic reasons
B. To reduce patient anxiety
C. To assist with consistent angle and location for cannulation
D. To show fistula location to new staff
✅ Correct answer: C
51. What is a primary reason for track loss in Buttonhole cannulation?
A. Using topical anesthetic
B. Daily use of blunt needles
C. Changing cannulation angle or depth
D. Applying antiseptic too early
✅ Correct answer: C
52. Which patient population may not be suitable for Buttonhole cannulation?
A. Pediatric patients with small fistulas
B. Adults with matured AVF
C. Patients performing home hemodialysis
D. Stable, long-term dialysis patients
✅ Correct answer: A
53. What is a recommended method to assess track readiness for blunt needle use?
A. Patient report of pain reduction
B. Formation of consistent scab
C. At least 6 successful sharp cannulations with same technique
D. Random attempt with blunt needle
✅ Correct answer: C
54. Buttonhole cannulation is especially helpful for patients who:
A. Require short-term access
B. Have poor hygiene practices
C. Need frequent catheter replacements
D. Have limited cannulation sites on the AVF
✅ Correct answer: D
55. Which step should immediately follow scab removal?
A. Apply gauze
B. Re-clean site with antiseptic
C. Start dialysis
D. Insert sharp needle
✅ Correct answer: B
56. If Buttonhole track is misaligned due to poor technique, what complication is most likely?
A. Hematuria
B. Thrombocytopenia
C. Infiltration and bruising
D. Seizures
✅ Correct answer: C
57. Which of the following statements is true regarding infection prevention in Buttonhole technique?
A. Scab removal can be skipped if the area looks clean
B. Hand hygiene is optional if gloves are worn
C. Antiseptic must be reapplied after scab removal
D. Patients should self-cannulate to prevent infection
✅ Correct answer: C
58. Why is it important to avoid “track switching” in Buttonhole sites?
A. It causes skin discoloration
B. It affects blood pressure
C. It may result in new tunnel formation or infiltration
D. It helps maintain symmetry
✅ Correct answer: C
59. A blunt needle should glide smoothly into a mature track. If resistance occurs, what’s the best step?
A. Force the needle
B. Ask another nurse to try
C. Withdraw, reassess angle, and reinsert gently
D. Switch to a larger gauge
✅ Correct answer: C
60. What is a best practice for tracking and maintaining Buttonhole cannulation quality?
A. Avoid documentation to reduce workload
B. Record cannulator, angle, depth, needle type daily
C. Rotate sites weekly to rest the area
D. Change antiseptic brand weekly
✅ Correct answer: B
