PICC Line Insertion & Maintenance 5 — Questions and Answers
Question 1: Which catheter gauge is most appropriate for power injection of IV contrast through a PICC?
- 24 Fr
- 18 Fr or larger (power-injectable rated) (Correct answer)
- Any gauge if flow rate is reduced
- 20 Fr standard PICC
Correct answer: 18 Fr or larger (power-injectable rated)
Power injection requires a power-injectable PICC rated for the flow rates and pressures used in CT contrast administration, typically 4–5 mL/sec.
Question 2: A PICC placed in the right arm has migrated into the right internal jugular vein as confirmed on X-ray. The most appropriate next action is:
- Withdraw the catheter 2 cm and re-X-ray
- Have the patient turn their head toward the insertion side and reposition under fluoroscopy (Correct answer)
- Remove the catheter and place a new one
- Continue use since the IJ is an acceptable central vein
Correct answer: Have the patient turn their head toward the insertion side and reposition under fluoroscopy
Repositioning maneuvers (head turn, arm repositioning, fluoroscopic guidance) can redirect a malpositioned PICC from the IJ back into the SVC.
Question 3: When obtaining blood cultures through a PICC, the nurse should:
- Draw blood only from the catheter and discard the first 10 mL
- Collect one set from the catheter and one from a peripheral site to differentiate CRBSI from bacteremia (Correct answer)
- Always remove the PICC before culturing
- Flush with heparin before drawing to prevent clotting in the sample
Correct answer: Collect one set from the catheter and one from a peripheral site to differentiate CRBSI from bacteremia
Paired blood cultures (catheter vs. peripheral) allow differential time-to-positivity analysis to determine whether the catheter is the infection source.
Question 4: Needle-free connectors (NFC) on PICC lines should be changed:
- Every 24 hours
- With every dressing change only
- Every 72–96 hours per INS guidelines or per manufacturer instructions (Correct answer)
- Only when visibly contaminated
Correct answer: Every 72–96 hours per INS guidelines or per manufacturer instructions
INS standards recommend changing NFCs at least every 72–96 hours, concurrent with tubing changes, to minimize infection risk.
Question 5: To confirm PICC tip placement, the gold standard imaging modality is:
- Bedside ultrasound of the neck
- Chest X-ray (posteroanterior or anteroposterior projection) (Correct answer)
- ECG-based tip confirmation only
- Fluoroscopy with contrast injection
Correct answer: Chest X-ray (posteroanterior or anteroposterior projection)
Chest X-ray remains the standard method for verifying PICC tip position before initiating infusion therapy.
Question 6: A nurse notes blood backflow into the PICC extension tubing that is not resolving with repositioning. This finding most likely suggests:
- Correct catheter placement and patent lumen
- Elevated central venous pressure or a valve issue in the connector (Correct answer)
- Catheter fracture requiring immediate removal
- Air embolism developing
Correct answer: Elevated central venous pressure or a valve issue in the connector
Blood reflux into extension tubing can result from elevated CVP, negative intrathoracic pressure, or a faulty needleless connector valve.
Question 7: Which of the following is a contraindication to PICC placement in a specific arm?
- Patient preference for the non-dominant arm
- AV fistula or graft on that extremity (Correct answer)
- Presence of peripheral IV on the same arm
- BMI greater than 30
Correct answer: AV fistula or graft on that extremity
An arteriovenous fistula or graft is a contraindication because PICC insertion risks thrombosis, infection, and permanent damage to the dialysis access.
PICC Line Insertion & Maintenance 5
Which catheter gauge is most appropriate for power injection of IV contrast through a PICC?