Buttonhole Cannulation--What do we know

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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

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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

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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

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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

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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

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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

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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

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8. A potential complication of Buttonhole cannulation is:
A. Pneumothorax
B. Peritonitis
C. Localized infection or abscess
D. Cardiac tamponade
✅ Correct answer: C

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Assessment of the New AVF for Maturity.

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Assessment of New AVF for Maturity – MCQ

1. What is the recommended minimum duration before a new AVF should be assessed for maturity?
A. 1 week
B. 2 weeks
C. 4-6 weeks
D. 10-12 weeks
Answer: C. 4-6 weeks

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2. Which of the following is not part of the 'rule of 6's' for AVF maturity?
A. Depth less than 6 mm
B. Diameter more than 6 mm
C. Flow rate more than 600 mL/min
D. Bruit audible for 6 seconds
Answer: D. Bruit audible for 6 seconds

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3. A mature AVF should have a blood flow rate of at least:
A. 200 mL/min
B. 400 mL/min
C. 600 mL/min
D. 1000 mL/min
Answer: C. 600 mL/min

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4. Which physical finding suggests an immature AVF?
A. Easily compressible vein
B. Continuous thrill during palpation
C. Collapsed vein on arm elevation
D. Shallow vein less than 6 mm deep
Answer: C. Collapsed vein on arm elevation

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5. What diagnostic tool is most commonly used to assess AVF maturity?
A. Chest X-ray
B. Doppler ultrasound
C. CT angiogram
D. Venogram
Answer: B. Doppler ultrasound

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6. The presence of a strong continuous thrill upon palpation indicates:
A. Thrombosis
B. Infection
C. Adequate AVF flow
D. Low blood pressure
Answer: C. Adequate AVF flow

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7. According to the KDOQI guidelines, how long after AVF creation should it ideally be used for dialysis if mature?
A. Immediately
B. Within 1 week
C. After 2 weeks
D. After 6 weeks
Answer: D. After 6 weeks

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8. What is the purpose of the “rule of 6’s” in AVF assessment?
A. To diagnose AVF thrombosis
B. To monitor infection
C. To evaluate AVF maturity
D. To plan surgical intervention
Answer: C. To evaluate AVF maturity

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9. Which of the following is a sign of AVF maturity suitable for cannulation?
A. No palpable thrill
B. Vein depth of 1.5 cm
C. Vein diameter of 7 mm
D. Pulsatile mass over the site
Answer: C. Vein diameter of 7 mm

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10. Which clinical sign during auscultation indicates an AVF with sufficient flow?
A. Continuous machinery murmur
B. No sound heard
C. Soft bruit only on compression
D. Bruit during both systole and diastole
Answer: D. Bruit during both systole and diastole

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11. Which of the following is a false statement regarding AVF maturation?
A. Maturation is influenced by the size of the vein and artery
B. Handgrip exercises can promote maturation
C. AVF should ideally be used within 3 days of creation
D. AVF may fail to mature due to venous stenosis
Answer: C. AVF should ideally be used within 3 days of creation

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12. The rule of 6’s includes all the following EXCEPT:
A. Minimum blood flow of 600 mL/min
B. Vein diameter of at least 6 mm
C. Vein depth of more than 6 cm
D. Length of usable vein > 6 cm
Answer: C. Vein depth of more than 6 cm
(Correct depth is less than 6 mm, not more than 6 cm)

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13. Which imaging study helps confirm stenosis if an AVF fails to mature?
A. Abdominal ultrasound
B. MRI scan
C. Fistulogram
D. Echocardiogram
Answer: C. Fistulogram

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14. Which of the following may delay AVF maturation?
A. Handgrip exercises
B. Arterial calcification
C. Normal venous anatomy
D. Daily vein palpation
Answer: B. Arterial calcification

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15. What is a key reason for routine physical examination of a new AVF?
A. Check blood sugar
B. Detect infection only
C. Evaluate thrill, bruit, and vein characteristics
D. Confirm anticoagulation dose
Answer: C. Evaluate thrill, bruit, and vein characteristics

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16. What is the typical frequency for monitoring a new AVF during its maturation period?
A. Daily
B. Weekly
C. Every 3 months
D. Only on the first day
Answer: B. Weekly

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17. A newly created AVF is assessed at 6 weeks and has no thrill or bruit. What is the most likely issue?
A. Hyperkalemia
B. Venous hypertension
C. Thrombosis or occlusion
D. Arterial steal syndrome
Answer: C. Thrombosis or occlusion

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18. The presence of a continuous thrill upon palpation and a bruit during both systole and diastole is associated with:
A. Infection
B. Adequate AVF flow
C. Inflow stenosis
D. Hematoma
Answer: B. Adequate AVF flow

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19. What vein depth is generally considered acceptable for successful AVF cannulation?
A. <3 mm
B. <6 mm
C. >10 mm
D. >12 mm
Answer: B. <6 mm

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20. In a maturing AVF, which of the following helps predict successful use for dialysis?
A. No palpable vein
B. Pulsatile mass
C. Straight segment of vein at least 6 cm
D. Redness and warmth at site
Answer: C. Straight segment of vein at least 6 cm

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21. A new AVF shows high-pitched bruit with weak thrill. What is the most probable cause?
A. Normal maturation
B. Venous outflow stenosis
C. Hypotension
D. Fistula rupture
Answer: B. Venous outflow stenosis

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22. Hand exercises post-AVF creation are encouraged to:
A. Prevent infection
B. Reduce swelling
C. Promote venous dilation and maturation
D. Lower blood pressure
Answer: C. Promote venous dilation and maturation

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23. What should be the ideal time gap between AVF creation and first cannulation attempt?
A. 1-2 days
B. 1 week
C. 4-6 weeks
D. 3 months
Answer: C. 4-6 weeks

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24. A 6-week-old AVF has good thrill and bruit but a narrow segment of vein. What’s the next best step?
A. Start using for dialysis immediately
B. Apply cold compress
C. Refer for ultrasound mapping
D. Clamp the AVF
Answer: C. Refer for ultrasound mapping

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25. A mature AVF should have how many cm of accessible straight vein for successful cannulation?
A. 1 cm
B. 3 cm
C. 6 cm
D. 10 cm
Answer: C. 6 cm

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26. During AVF assessment, which of the following indicates inadequate inflow?
A. Strong continuous thrill
B. High-pitched bruit
C. Weak or absent thrill
D. Soft compressible vein
Answer: C. Weak or absent thrill

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27. The term “non-maturing fistula” is typically applied when the AVF fails to mature after:
A. 1 week
B. 2 weeks
C. 4 weeks
D. 6 weeks
Answer: D. 6 weeks

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28. The most common cause of primary AVF failure is:
A. Infection
B. Hematoma
C. Central venous stenosis
D. Juxta-anastomotic stenosis
Answer: D. Juxta-anastomotic stenosis

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29. Which of the following is NOT part of a physical examination of AVF maturity?
A. Palpation of thrill
B. Auscultation of bruit
C. Monitoring blood pressure
D. Assessment of vein diameter and depth
Answer: C. Monitoring blood pressure

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30. A newly formed AVF with swelling, redness, and tenderness at the site may indicate:
A. Normal postoperative change
B. Infection or hematoma
C. Proper AVF dilation
D. High fistula flow
Answer: B. Infection or hematoma

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31. Doppler ultrasound shows AVF flow at 350 mL/min, vein diameter 4 mm, and depth 10 mm. What does this indicate?
A. Fistula ready for use
B. Fistula is mature
C. Fistula is immature
D. Normal result
Answer: C. Fistula is immature

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32. During assessment, a long segment of the vein collapses with arm elevation. This suggests:
A. Normal AVF
B. Venous stenosis
C. Patent outflow
D. Arterial steal
Answer: B. Venous stenosis

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33. In clinical practice, how often should physical exams of a new AVF be conducted before first use?
A. Only on day 1
B. Weekly until use
C. Monthly
D. Only when symptoms arise
Answer: B. Weekly until use

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34. Which of the following is LEAST useful in evaluating AVF maturity?
A. Vein compressibility
B. Doppler flow measurement
C. Skin pigmentation over site
D. Palpation of thrill
Answer: C. Skin pigmentation over site

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35. What is the key factor in determining whether a new AVF can be successfully used for two-needle cannulation?
A. Flow rate only
B. Bruit alone
C. Vein size, depth, and accessible length
D. Patient’s age
Answer: C. Vein size, depth, and accessible length

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36. A new AVF is difficult to visualize and cannulate due to depth. What is the most appropriate management?
A. Apply cold packs
B. Immediate use for dialysis
C. Surgical superficialization
D. Start heparin infusion
Answer: C. Surgical superficialization

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37. The term "primary failure" of AVF refers to:
A. Fistula infection
B. Thrombosis after 6 months
C. Failure to mature adequately for use
D. Stenosis due to repeated cannulation
Answer: C. Failure to mature adequately for use

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38. What is the minimum vein diameter required for an AVF to be considered mature?
A. 2 mm
B. 4 mm
C. 6 mm
D. 10 mm
Answer: C. 6 mm

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39. Which intervention is often performed when an AVF fails to mature due to a stenotic segment?
A. Antibiotic infusion
B. Balloon angioplasty
C. Vein ligation
D. Compression therapy
Answer: B. Balloon angioplasty

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40. The absence of bruit and thrill on physical examination of a new AVF most likely indicates:
A. High flow AVF
B. Hyperfunctioning AVF
C. AVF occlusion or thrombosis
D. Venous spasm
Answer: C. AVF occlusion or thrombosis

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41. Which of the following is the most sensitive imaging method for evaluating AVF blood flow and vessel size?
A. CT angiogram
B. Chest X-ray
C. Doppler ultrasound
D. MRI
Answer: C. Doppler ultrasound

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42. Why is it important to assess the straight segment length of the vein in AVF evaluation?
A. Prevent thrombosis
B. Determine needle placement zone
C. Avoid infection
D. Reduce blood pressure
Answer: B. Determine needle placement zone

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43. What is the ideal depth from the skin surface for a mature AVF vein to allow successful cannulation?
A. Less than 6 mm
B. More than 8 mm
C. 1–2 cm
D. 3–4 cm
Answer: A. Less than 6 mm

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44. Which patient factor may delay or impair AVF maturation?
A. Young age
B. Diabetes mellitus
C. Handgrip exercises
D. High protein diet
Answer: B. Diabetes mellitus

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45. A bruit that disappears suddenly from a previously mature AVF suggests:
A. Normal function
B. Venous hypertension
C. Acute thrombosis
D. Low flow AVF
Answer: C. Acute thrombosis

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46. What is the most common reason for an AVF to fail to mature within the expected time frame?
A. Patient non-compliance
B. Early cannulation
C. Venous stenosis near the anastomosis
D. High calcium levels
Answer: C. Venous stenosis near the anastomosis

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47. A mature AVF should support a dialysis blood flow rate of at least:
A. 200 mL/min
B. 400 mL/min
C. 500 mL/min
D. 600 mL/min
Answer: D. 600 mL/min

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48. A weak, discontinuous thrill in a new AVF may be a sign of:
A. Proper function
B. Outflow obstruction
C. Hypotension
D. Normal adaptation
Answer: B. Outflow obstruction

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49. Why should tourniquet use be minimized during AVF maturation?
A. It causes infection
B. It impairs arterial inflow and causes vein trauma
C. It dilates the fistula too much
D. It falsely increases bruit sounds
Answer: B. It impairs arterial inflow and causes vein trauma

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50. A well-functioning AVF should exhibit which characteristic on auscultation?
A. No sound
B. Bruit only during systole
C. Bruit during both systole and diastole
D. Bruit only when compressed
Answer: C. Bruit during both systole and diastole

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51. Before using a new AVF for dialysis, the vein should ideally be:
A. Sclerosed and deep
B. Soft, compressible, and superficial
C. Narrow and non-pulsatile
D. Indurated and firm
Answer: B. Soft, compressible, and superficial

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52. A bruit that is high-pitched and localized near the anastomosis likely indicates:
A. Hyperfunctioning AVF
B. Normal maturity
C. Stenosis at the anastomotic site
D. Low blood flow
Answer: C. Stenosis at the anastomotic site

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53. What is the primary goal of pre-cannulation assessment of AVF?
A. Prevent bleeding
B. Assess infection
C. Confirm functional maturity for successful dialysis
D. Evaluate for AV graft need
Answer: C. Confirm functional maturity for successful dialysis

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54. Which of the following may enhance AVF maturation post-surgery?
A. Arm immobilization
B. Isometric handgrip exercises
C. High-protein diet
D. Smoking
Answer: B. Isometric handgrip exercises

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55. When assessing an AVF for the first time after surgery, what is the most important early sign of patency?
A. Audible bruit only
B. Palpable thrill immediately post-op
C. High blood pressure
D. Skin color changes
Answer: B. Palpable thrill immediately post-op

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56. Which of the following findings during AVF assessment would most likely require surgical or interventional correction?
A. Soft thrill and continuous bruit
B. Vein diameter of 7 mm
C. Flow rate of 300 mL/min at 6 weeks
D. Palpable, superficial vein
Answer: C. Flow rate of 300 mL/min at 6 weeks

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57. A newly created AVF is not maturing and the patient has central venous stenosis. What is a common clinical finding?
A. Warmth over the site
B. Enlarged collateral veins in the upper chest
C. Bounding pulse in the radial artery
D. Pale hand on AVF side
Answer: B. Enlarged collateral veins in the upper chest

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58. What is the recommended follow-up action if an AVF fails to mature by 6 weeks?
A. Continue monitoring until 3 months
B. Begin dialysis through the AVF
C. Refer for imaging (e.g., Doppler) and possible angioplasty
D. Apply hot packs daily
Answer: C. Refer for imaging (e.g., Doppler) and possible angioplasty

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59. An AVF with no thrill but an audible bruit most likely indicates:
A. High flow AVF
B. Maturation complete
C. Thrombosed fistula
D. Partial outflow obstruction
Answer: D. Partial outflow obstruction

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60. When planning for dialysis initiation, what is the primary criterion to determine if the AVF is ready for use?
A. Time since creation
B. Size of the incision scar
C. Palpable thrill and adequate vein length
D. Bruit during systole only
Answer: C. Palpable thrill and adequate vein length

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61. Why is it important to assess both bruit and thrill in AVF evaluation?
A. To monitor infection
B. They confirm the presence and adequacy of blood flow
C. They help reduce blood pressure
D. They assess the patient’s pain level
Answer: B. They confirm the presence and adequacy of blood flow

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62. In clinical practice, what does a “short segment” AVF refer to?
A. A fistula that is less than 1 week old
B. Vein segment < 6 cm suitable for cannulation
C. Narrow artery
D. AVF with two anastomoses
Answer: B. Vein segment < 6 cm suitable for cannulation

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63. Which patient factor has the strongest association with poor AVF maturation?
A. Female gender
B. History of stroke
C. Obesity
D. Diabetes and peripheral vascular disease
Answer: D. Diabetes and peripheral vascular disease

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64. What is the best non-invasive method to evaluate an AVF that fails clinical maturation assessment?
A. MRI
B. Venogram
C. Doppler ultrasound
D. Chest X-ray
Answer: C. Doppler ultrasound

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65. When assessing a mature AVF, which parameter is NOT a part of the standard “rule of 6's”?
A. Vein depth < 6 mm
B. Vein diameter ≥ 6 mm
C. Straight vein segment ≥ 6 cm
D. Access pressure < 60 mmHg
Answer: D. Access pressure < 60 mmHg

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66. What is the most appropriate next step when an AVF has adequate thrill and bruit but insufficient vein dilation?
A. Start using it for dialysis
B. Ligate the AVF
C. Refer for balloon angioplasty
D. Apply ice packs
Answer: C. Refer for balloon angioplasty

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67. Which of the following is considered a functional AVF?
A. One that produces bruit only
B. One that has been surgically created
C. One that can be successfully cannulated with two needles for adequate dialysis
D. One with an incision wound healing well
Answer: C. One that can be successfully cannulated with two needles for adequate dialysis

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68. A thrill is best assessed using which technique?
A. Stethoscope over AVF
B. Gentle palpation with fingers over the vein
C. Applying a BP cuff
D. Using a tourniquet
Answer: B. Gentle palpation with fingers over the vein

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69. The absence of bruit in a previously functioning AVF is most likely due to:
A. Vasodilation
B. Hematoma
C. AVF thrombosis
D. Excessive flow
Answer: C. AVF thrombosis

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70. In physical examination of a new AVF, the term “augmentation test” refers to:
A. Elevating the arm to observe venous collapse
B. Compressing outflow and observing increased thrill
C. Using ultrasound to measure vein size
D. Checking for arm circumference
Answer: B. Compressing outflow and observing increased thrill

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71. What is the significance of a strong pulsatile AVF with no thrill?
A. It is normal
B. Indicates venous hypertension or outflow stenosis
C. Ready for dialysis
D. Suggests high cardiac output
Answer: B. Indicates venous hypertension or outflow stenosis

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72. Which physical finding is most suggestive of early AVF stenosis?
A. Strong continuous thrill
B. High-pitched bruit localized to a single area
C. Deep, compressible vein
D. Soft bruit over full length of vein
Answer: B. High-pitched bruit localized to a single area

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73. In assessing AVF maturity, the straight segment should be free of curves and branches for at least:
A. 3 cm
B. 5 cm
C. 6 cm
D. 10 cm
Answer: C. 6 cm

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74. What is the best indicator that an AVF can consistently provide adequate dialysis?
A. Presence of surgical scar
B. Use of ultrasound alone
C. Successful two-needle cannulation with prescribed blood flow
D. Vein that “pops up” when arm is raised
Answer: C. Successful two-needle cannulation with prescribed blood flow

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75. A non-maturing AVF that shows narrowing at the anastomosis on Doppler should be:
A. Observed for another month
B. Used with a single needle
C. Considered for surgical revision or angioplasty
D. Tied off and removed
Answer: C. Considered for surgical revision or angioplasty

 

76. A patient’s AVF has a vein diameter of 7 mm, depth of 4 mm, and flow of 700 mL/min. What does this indicate?

A. Immature fistula
B. Ready for first cannulation
C. Fistula thrombosis
D. Inflow stenosis
Answer: B. Ready for first cannulation

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77. Which feature would most likely delay cannulation despite acceptable AVF blood flow?
A. Soft thrill
B. Vein depth of 12 mm
C. Bruit on auscultation
D. Straight segment of 7 cm
Answer: B. Vein depth of 12 mm

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78. A 6-week-old AVF has a continuous thrill but no visible vein. What is the most appropriate next step?
A. Use tourniquet and attempt cannulation
B. Proceed to dialysis with single-needle cannulation
C. Refer for ultrasound to assess depth
D. Ligation of fistula
Answer: C. Refer for ultrasound to assess depth

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79. During assessment, you find a mature AVF with 6 mm vein, shallow depth, but only 400 mL/min flow. What is the likely status?
A. Ready for full use
B. Still maturing
C. High-risk of infection
D. Should be abandoned
Answer: B. Still maturing

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80. A dialysis nurse reports difficulty with two-needle cannulation despite AVF thrill and bruit. What is the likely cause?
A. Arterial aneurysm
B. Central venous stenosis
C. Short cannulation zone or deep vein
D. Infection
Answer: C. Short cannulation zone or deep vein

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81. What tool helps best in mapping out a superficial segment for cannulation?
A. Tourniquet
B. Ultrasound
C. Stethoscope
D. BP cuff
Answer: B. Ultrasound

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82. If a thrill is only felt during systole, the likely AVF issue is:
A. Complete thrombosis
B. Normal function
C. Inflow stenosis
D. Outflow stenosis
Answer: D. Outflow stenosis

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83. Which of the following would not indicate a mature AVF?
A. 6 cm straight segment
B. 6 mm vein diameter
C. 3 cm depth from skin
D. 700 mL/min flow rate
Answer: C. 3 cm depth from skin

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84. What is the clinical purpose of using the “augmentation test” during AVF assessment?
A. Confirm patency of AV graft
B. Identify arterial steal
C. Detect inflow problems
D. Identify infection
Answer: C. Detect inflow problems

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85. An AVF with a flat bruit and no thrill on palpation is most likely:
A. Mature and functional
B. Ready for cannulation
C. Thrombosed or severely stenosed
D. Hyperfunctioning
Answer: C. Thrombosed or severely stenosed

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86. After 6 weeks, an AVF has excellent thrill and bruit but cannulation repeatedly infiltrates. What is the likely issue?
A. Deep vein
B. High flow
C. Arterial steal
D. Maturation complete
Answer: A. Deep vein

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87. A newly matured AVF shows 6 mm vein diameter, 5 mm depth, and 800 mL/min flow, but bruising after every cannulation. What might be the cause?
A. Early use
B. Incorrect needle angle or technique
C. Low AVF pressure
D. Infection
Answer: B. Incorrect needle angle or technique

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88. A patient with a maturing AVF has difficulty doing handgrip exercises. What is an alternative recommendation?
A. Avoid using the arm
B. Isometric ball squeeze exercises
C. Blood pressure cuff inflation
D. Passive elevation
Answer: B. Isometric ball squeeze exercises

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89. Which of the following signs suggests inflow stenosis rather than outflow stenosis?
A. Thrill present only during diastole
B. High-pitched localized bruit
C. Weak or absent thrill even on augmentation
D. Vein collapses with elevation
Answer: C. Weak or absent thrill even on augmentation

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90. A maturing AVF with strong thrill and bruit but short usable vein (<3 cm) should be:
A. Used immediately
B. Declared mature
C. Evaluated for surgical revision
D. Ignored
Answer: C. Evaluated for surgical revision

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91. What is the importance of mapping veins preoperatively for AVF creation?
A. Predict the duration of dialysis
B. Ensure vein diameter and patency are suitable
C. Identify AVF thrill early
D. Improve infection control
Answer: B. Ensure vein diameter and patency are suitable

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92. A sudden loss of bruit and thrill in a previously functional AVF most likely indicates:
A. Successful maturation
B. Fistula collapse
C. Infection
D. Acute thrombosis
Answer: D. Acute thrombosis

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93. In assessing AVF cannulation readiness, why is depth from the skin important?
A. Deeper veins are stronger
B. Shallow veins resist flow
C. Deeper veins are harder to cannulate and increase infiltration risk
D. It predicts infection risk
Answer: C. Deeper veins are harder to cannulate and increase infiltration risk

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94. What is the recommended action if an AVF flow is <500 mL/min after 6 weeks?
A. Proceed with use
B. Start anticoagulants
C. Refer for ultrasound and consider angioplasty
D. Bandage the arm
Answer: C. Refer for ultrasound and consider angioplasty

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95. Which sign indicates high flow AVF, potentially leading to cardiac strain?
A. Systolic-only bruit
B. Continuous low-pitched bruit
C. Bounding pulse, strong thrill, and venous hypertension
D. Deep narrow vein
Answer: C. Bounding pulse, strong thrill, and venous hypertension

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96. Which of the following findings is least useful when determining AVF readiness for dialysis?
A. Vein diameter
B. Depth from skin
C. Skin color over the AVF
D. Flow rate
Answer: C. Skin color over the AVF

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97. A bruit is heard only during systole. This is a classic sign of:
A. Maturation complete
B. Inflow stenosis
C. Normal variant
D. Arterial aneurysm
Answer: B. Inflow stenosis

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98. An AVF with 6 mm diameter, 4 mm depth, but curved tortuous segments is considered:
A. Ready for two-needle use
B. At risk of infiltration; needs further evaluation
C. Functionally mature
D. A sign of thrombosis
Answer: B. At risk of infiltration; needs further evaluation

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99. You are unable to palpate a thrill during AVF exam, but the patient is hypotensive. What should you do first?
A. Document as thrombosed
B. Wait for the next shift
C. Reassess after stabilizing blood pressure
D. Initiate heparin
Answer: C. Reassess after stabilizing blood pressure

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100. The most reliable combination of signs indicating AVF maturity includes:
A. Bruit and elevated WBC
B. Vein length and edema
C. Vein diameter ≥ 6 mm, depth ≤ 6 mm, flow ≥ 600 mL/min
D. Patient-reported thrill only
Answer: C. Vein diameter ≥ 6 mm, depth ≤ 6 mm, flow ≥ 600 mL/min

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