Patient Assessment Flashcards

Which assessment finding in a patient with an existing PICC would MOST suggest catheter-associated deep vein thrombosis (DVT)?

Answer: Swelling, pain, and warmth of the entire arm

Unilateral arm swelling, pain, and warmth are classic signs of upper extremity DVT associated with catheter presence.

When performing a pre-insertion assessment for a central line, the nurse notes a patient's platelet count is 42,000/µL. What is the appropriate next step?

Answer: Document and notify the provider before proceeding

Thrombocytopenia below 50,000/µL significantly increases bleeding risk and requires provider notification for risk-benefit evaluation before insertion.

A nurse is assessing a patient for peripheral IV insertion and notes the skin over the intended vein is ecchymotic from prior attempts. What does this finding indicate?

Answer: Avoid that site to reduce the risk of unsuccessful cannulation and patient discomfort

Ecchymotic skin over a vein indicates trauma to surrounding tissue, making venipuncture more difficult and painful; an alternate site should be selected.

During assessment, a patient receiving IV vancomycin through a peripheral IV complains of burning and the nurse observes a red streak along the vein proximal to the insertion site. This finding is consistent with:

Answer: Chemical phlebitis

A red streak along the vein with burning pain is characteristic of chemical phlebitis caused by irritating medications such as vancomycin.

Which patient factor MOST increases the risk of catheter-related bloodstream infection (CRBSI) and should be documented during assessment?

Answer: Immunocompromised status (e.g., neutropenia, HIV)

Immunocompromised patients have impaired defenses against pathogens, significantly elevating their risk for CRBSI.

A nurse assesses a patient's central venous catheter dressing and notes the dressing is damp and partially lifted at one corner. The site itself appears clean. What is the correct action?

Answer: Perform a full dressing change using aseptic technique

A compromised (damp or non-intact) dressing requires immediate replacement using aseptic technique to prevent bacterial migration to the catheter site.

During shift assessment of a patient with a tunneled CVC, the nurse notices the external catheter length is 3 cm longer than the documented length from insertion. What does this finding suggest?

Answer: The catheter has migrated outward and tip position may have changed

A change in external catheter length indicates potential catheter migration; tip position must be verified with imaging before further use.