Patient Assessment Flashcards

A patient presents with a port-a-cath that has not been accessed in 8 months. Prior to drawing blood from the port, the nurse should FIRST:

Answer: Assess port patency by injecting 10 mL normal saline and feeling for resistance

Assessing for patency by evaluating resistance to flush with normal saline determines whether the port and catheter are functional before blood withdrawal.

When assessing a patient for appropriateness of a midline catheter, which therapy would be a contraindication for midline use?

Answer: Continuous vesicant chemotherapy infusion

Vesicant chemotherapy must be administered through a central venous catheter because extravasation from a midline can cause severe tissue necrosis.

A nurse assesses a patient's arm after peripheral IV insertion and notes the infusion is flowing by gravity but the site is cool, pale, and slightly swollen. This presentation is MOST consistent with:

Answer: Infiltration

Coolness, pallor, and swelling at the IV site indicate infiltration, where fluid is leaking into the surrounding subcutaneous tissue rather than the vein.

Which assessment finding in a patient with a femoral central venous catheter would prompt the nurse to immediately notify the physician?

Answer: Hematoma formation and expanding bruising at the groin insertion site

Expanding hematoma at a femoral CVC site suggests vascular injury or inadequate hemostasis and requires urgent physician notification.

When assessing a patient's PICC for a blood draw, the nurse aspirates and obtains no blood return. Which intervention should be attempted FIRST?

Answer: Reposition the patient's arm and have them take a deep breath, then reattempt

Repositioning the arm and changing intrathoracic pressure can relieve tip malposition against the vessel wall, restoring blood return.

A nurse is assessing a patient for vascular access device selection. The patient needs IV therapy for an expected 3 weeks and has a documented latex allergy. Which consideration is MOST important during device assessment?

Answer: Verify all components of the vascular access system are latex-free

All IV equipment, including tubing, injection caps, and gloves, must be confirmed latex-free to prevent allergic reaction in patients with latex allergy.

During assessment of a patient with a subclavian central line, the nurse notes the patient's oxygen saturation has dropped to 89% and he is complaining of sudden chest pain and shortness of breath following the recent line insertion. The nurse should FIRST suspect:

Answer: Pneumothorax

Sudden respiratory distress and chest pain following subclavian CVC insertion are classic signs of pneumothorax, a known complication of subclavian access.