NCLEX-RN Exam - Topic 2 Question 4 Discussion

Actual exam question for NCLEX's NCLEX-RN exam

Question #: 4
Topic #: 2

A female client decides on hemodialysis. She has an internal vascular access device placed. To ensure patency of the device, the nurse must:

AAssess the site for leakage of blood or fluids

BAuscultate the site for a bruit

CAssess the site for bruising or hematoma

DInspect the site for color, warmth, and sensation

Show Suggested Answer

Suggested Answer: B

(A) This is an internal device. Assessment of the site should include assessing for swelling, pain, warmth, and discoloration. This measure does not assess patency. (B) The presence of a bruit indicates good blood flow through the device. (C) The nurse should inspect the site for bruising or hematoma; however, this measure does not assure patency of the device. (D) The nurse should inspect the vascular access site frequently for signs of infection. However, this does not assure patency.

by Arminda at Jun 14, 2025, 05:21 AM

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Carmen

5 months ago

Bruit is the way to go, no doubt about it!

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Catherin

5 months ago

Wait, isn't bruising a sign of something wrong?

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Heike

6 months ago

I thought assessing for leakage was key too.

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France

6 months ago

Definitely check for color and warmth as well!

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Chery

6 months ago

Gotta auscultate for that bruit! Super important.

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Paris

6 months ago

I feel like inspecting for color and warmth is also important, but I can't recall if that directly relates to patency.

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Malika

7 months ago

I practiced a similar question where we had to determine the best way to assess an AV fistula. I think auscultating for a bruit was the answer there too.

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Kindra

7 months ago

I'm not entirely sure, but I feel like assessing for leakage might be more about complications rather than patency.

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Anna

7 months ago

I remember we talked about checking for a bruit to assess the patency of the vascular access. I think that's important, right?

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Ellsworth

7 months ago

I'm feeling a little lost on this one. There are a few different things we could check, like auscultating for a bruit or just doing a general assessment of the site. I'll have to think this through carefully before making a decision.

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Burma

7 months ago

Okay, I've got this. The key is to monitor the site for any signs of complications, like bruising, hematoma, or changes in color, warmth, and sensation. I'll go with option D to cover all those bases.

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Lai

8 months ago

Hmm, I'm a bit unsure here. I know we need to ensure the device is working properly, but I'm not sure if assessing for leakage is the best approach. Maybe I should consider the other options as well.

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Vallie

8 months ago

This seems like a straightforward question about maintaining the patency of a vascular access device. I think I'll go with option A - assessing the site for any leakage of blood or fluids.

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Scarlet

11 months ago

I'm not sure, but I think it might also be D) Inspect the site for color, warmth, and sensation to ensure there are no complications.

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Alpha

11 months ago

Ha! Checking for a bruit? What is this, a medical mystery novel? I'll go with C - checking for bruising or hematoma seems like the most practical option.

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