Patient Assessment Flashcards

A nurse is assessing a patient who will receive long-term home IV therapy. Which factor is MOST important to assess when selecting a vascular access device for discharge planning?

Answer: Patient's and caregiver's ability to manage and maintain the device

The patient's and caregiver's ability to safely manage the device at home is the primary safety consideration for device selection in home infusion therapy.

Which vein characteristic found on ultrasound assessment would MOST indicate suitability for PICC insertion?

Answer: Vein is compressible, anechoic, and measures at least 4 mm in diameter

A compressible, anechoic (fluid-filled) vein of at least 4 mm diameter is considered ideal for PICC insertion via ultrasound guidance.

A patient's medical history documents prior radiation therapy to the right chest and axilla. How should this information influence vascular access assessment?

Answer: Avoid the right upper extremity and right-sided central access due to fibrosis and poor healing

Prior radiation causes tissue fibrosis, vascular damage, and impaired healing, making the radiated area unsuitable for vascular access.

During assessment of a pediatric patient requiring IV access, the nurse notes the child is highly anxious and crying. Which action should the nurse prioritize BEFORE attempting IV insertion?

Answer: Use age-appropriate distraction techniques and allow a parent to be present

Child life techniques such as distraction and parental presence reduce procedure-related anxiety and improve cooperation and safety during venipuncture.

A nurse assesses an elderly patient's veins and notes they are visible but roll when touched and the skin is extremely fragile. Which technique modification is MOST appropriate?

Answer: Use a smaller gauge needle, anchor the vein with traction, and avoid excessive tourniquet pressure

In elderly patients, stabilizing rolling veins with traction and using a small gauge with minimal tourniquet pressure reduces vessel trauma and skin tearing.

When assessing catheter function in a patient with an implanted port, the nurse notes resistance when flushing and inability to withdraw blood. After repositioning fails, the next appropriate step is to:

Answer: Administer a fibrinolytic agent per protocol and reassess patency

When repositioning does not restore patency, a fibrinolytic agent such as alteplase is indicated per protocol to clear a suspected thrombus.

Which assessment finding in a patient with a long-term tunneled catheter should prompt the nurse to withhold use of the device and notify the provider IMMEDIATELY?

Answer: Visible purulent drainage and fever of 39.2°C (102.6°F)

Purulent drainage at the catheter site combined with fever are signs of catheter-related infection requiring urgent provider notification and possible catheter removal.