PICC Anatomy & Vascular Access Evaluation 5 — Questions and Answers
Question 1: The azygos vein, into which a PICC can malposition, enters the SVC at approximately which vertebral level?
- T2
- T4 (Correct answer)
- T6
- T8
Correct answer: T4
The azygos vein arches over the right main bronchus and drains into the posterior aspect of the SVC at approximately the T4 vertebral level.
Question 2: A patient with a BMI of 42 requires PICC placement. The bedside nurse cannot visualize or palpate any arm veins. Which technology is the standard of care for vascular access in this situation?
- Blind landmark technique using the antecubital fossa
- Real-time ultrasound guidance (Correct answer)
- Near-infrared vein visualization device only
- Fluoroscopy-guided insertion in interventional radiology
Correct answer: Real-time ultrasound guidance
Real-time ultrasound guidance is the standard of care for PICC insertion, especially in patients where veins are not visible or palpable.
Question 3: During vein assessment, the PICC nurse identifies that the patient's basilic vein has a valve 2 cm proximal to the intended insertion site. What is the best course of action?
- Choose a different vein immediately
- Insert distal to the valve and use gentle, steady advancement to pass through it (Correct answer)
- Insert proximal to the valve
- Use a larger gauge catheter to force through the valve
Correct answer: Insert distal to the valve and use gentle, steady advancement to pass through it
Venous valves can usually be navigated by inserting distal to the valve and using gentle, consistent advancement; saline flushing or slight catheter rotation may also assist passage.
Question 4: Which of the following veins is a paired deep vein that accompanies the brachial artery and should be avoided for PICC insertion due to increased risk of arterial injury?
- Basilic vein
- Cephalic vein
- Brachial veins (venae comitantes) (Correct answer)
- Median cubital vein
Correct answer: Brachial veins (venae comitantes)
The brachial veins (venae comitantes) travel in close proximity to the brachial artery and are deep veins that carry higher risk of arterial puncture; they should not be the primary PICC target.
Question 5: The right brachiocephalic vein is shorter and more vertical than the left. Which clinical implication does this have for PICC insertion?
- Right-sided PICC insertion results in a longer catheter path to the SVC
- Right-sided PICC insertion typically requires a shorter catheter length than left-sided insertion (Correct answer)
- Left-sided insertion carries a lower risk of SVC perforation
- There is no clinically relevant difference between right and left sides
Correct answer: Right-sided PICC insertion typically requires a shorter catheter length than left-sided insertion
Because the right brachiocephalic vein is shorter and takes a more direct route to the SVC, right-sided PICCs generally require shorter catheter lengths than left-sided insertions.
Question 6: A PICC nurse notices on post-insertion chest X-ray that the catheter tip is in the right ventricle. What is the immediate priority action?
- Continue infusion at a reduced rate until the physician reviews
- Withdraw the catheter to reposition the tip to the cavoatrial junction before use (Correct answer)
- Obtain an ECG and then continue using the PICC
- Request a repeat X-ray in 4 hours to reassess
Correct answer: Withdraw the catheter to reposition the tip to the cavoatrial junction before use
A tip in the right ventricle must be immediately withdrawn to the cavoatrial junction or lower SVC, as right ventricular placement risks arrhythmias and cardiac perforation.
Question 7: When evaluating upper extremity veins for PICC candidacy, the nurse should document the vein's response to which maneuver that helps distinguish adequate from inadequate vessels?
- Valsalva maneuver to assess arterial pulsatility
- Augmentation (distal compression) on Doppler ultrasound to confirm venous patency and flow (Correct answer)
- Allen test to evaluate palmar collateral circulation
- Trendelenburg positioning to assess valve competency
Correct answer: Augmentation (distal compression) on Doppler ultrasound to confirm venous patency and flow
Augmentation via distal limb compression during Doppler ultrasound demonstrates venous flow augmentation, confirming vessel patency and absence of proximal obstruction.
PICC Anatomy & Vascular Access Evaluation 5
The azygos vein, into which a PICC can malposition, enters the SVC at approximately which vertebral level?