Patient Assessment & Care Planning Flashcards

A hemodialysis patient has a functioning AV fistula in the left arm. Which action is contraindicated?

Answer: Performing venipuncture in the left arm

Venipuncture, IV insertion, and blood pressure readings in the fistula arm can damage the access.

An older adult has fragile skin. Which intervention best prevents medical adhesive-related skin injury (MARSI) at the catheter site?

Answer: Apply a skin barrier film before the dressing

Applying a barrier film to the area under the adhesive, not the insertion site, protects fragile skin from stripping.

Which site should be avoided for peripheral IV placement in a toddler who is walking?

Answer: Foot veins

Foot veins should be avoided in children who walk because this limits mobility and raises the risk of complications.

Which factor most increases the risk of PICC-related deep vein thrombosis?

Answer: A catheter-to-vein ratio greater than 45%

A large catheter relative to the vein, often a multi-lumen device, reduces blood flow and raises the risk of thrombosis.

How often should the nurse assess whether a CVAD is still needed?

Answer: Daily

INS recommends assessing daily whether the device is still needed and removing it promptly when it is no longer necessary.

Which method best confirms that a patient understands home vascular access care instructions?

Answer: Teach-back, with the patient demonstrating or explaining the care in their own words

Teach-back checks comprehension directly and accounts for differences in health literacy.

Where should baseline upper-arm circumference be measured before PICC insertion?

Answer: 10 cm above the antecubital fossa

Measuring 10 cm above the antecubital fossa gives a consistent reference for detecting edema or DVT later.