Maintenance and Care Flashcards

Which nursing action is most effective in preventing phlebitis in a peripheral IV site?

Answer: Rotating peripheral IV sites every 72-96 hours and assessing each site at least every 4 hours

Regular site rotation and frequent assessment allow early detection and prompt discontinuation before phlebitis progresses to a serious complication.

A patient receiving IV vancomycin through a peripheral line develops a grade 2 phlebitis. What is the most appropriate next action?

Answer: Discontinue the peripheral IV, place a new one in a different site, and consider obtaining a PICC

Grade 2 phlebitis with an irritant medication like vancomycin requires discontinuing the site and considering a more appropriate long-term access device such as a PICC.

Which practice is recommended to reduce the risk of CLABSI according to the central line maintenance bundle?

Answer: Daily review of catheter necessity and prompt removal when no longer needed

Daily assessment and prompt removal when the CVC is no longer clinically necessary is a core component of the CLABSI prevention maintenance bundle.

What is the correct technique for blood sampling from a CVC lumen that is infusing a continuous medication?

Answer: Stop the infusion, wait per facility policy, discard the appropriate waste volume, then draw the sample

Stopping the infusion and discarding the appropriate waste volume prevents sample dilution or contamination by the infusing medication.

Which condition is a contraindication to placing a PICC in the upper extremity on the affected side?

Answer: Mastectomy with axillary lymph node dissection on the same side

Axillary lymph node dissection impairs lymphatic and venous drainage, significantly increasing the risk of lymphedema and thrombosis if a PICC is placed on the same side.

A nurse is preparing to access an implanted port. After palpating the port, which gauge of non-coring (Huber) needle is most commonly used for routine access?

Answer: 19-22 gauge Huber needle

A 19-22 gauge Huber needle is used to access implanted ports; the non-coring design preserves the silicone septum for multiple punctures over the device's lifespan.

During a routine assessment, a nurse notices the patient's PICC arm has developed new pitting edema and the patient reports the infusion feels 'tight.' What complication should be suspected?

Answer: Extravasation or infiltration of infusate into surrounding tissue

New edema in the extremity and patient-reported tightness during infusion are hallmark signs of infiltration or extravasation, requiring immediate cessation of the infusion.