VA-BC Documentation 2 — Questions and Answers
Question 1: When documenting PICC tip placement confirmed by chest X-ray, which anatomical landmark should be recorded as the target location?
- Superior vena cava/cavoatrial junction (Correct answer)
- Subclavian vein
- Right ventricle
- Axillary vein
Correct answer: Superior vena cava/cavoatrial junction
The ideal PICC tip position is at the superior vena cava/cavoatrial junction, and this must be documented along with the method of confirmation.
Question 2: Which element is MOST critical to document when a patient refuses vascular access education prior to discharge?
- The patient's stated reason for refusal and that risks of non-compliance were explained (Correct answer)
- Only the nurse's initials indicating education was attempted
- The time education was scheduled
- The physician's contact information given to patient
Correct answer: The patient's stated reason for refusal and that risks of non-compliance were explained
Documenting the reason for refusal and that risks were communicated creates a legally defensible record and satisfies informed refusal requirements.
Question 3: A nurse draws blood from a central venous catheter and discards the first 5 mL. What must be documented regarding this discard?
- Amount discarded and that waste was witnessed per policy (Correct answer)
- Only the volume of blood drawn for the lab
- The color of the discarded blood
- No documentation is required for discarded blood
Correct answer: Amount discarded and that waste was witnessed per policy
Discard volumes from CVCs must be documented along with witness verification to comply with controlled substance and institutional waste policies.
Question 4: How should multiple failed venipuncture attempts be documented in the medical record?
- Number of attempts, sites tried, gauge used, and reason for difficulty (Correct answer)
- Only the final successful attempt
- Failed attempts in nursing notes only, not the MAR
- A single entry stating 'difficult access'
Correct answer: Number of attempts, sites tried, gauge used, and reason for difficulty
Each attempt should be documented with anatomical site, needle gauge, number of attempts, and contributing factors to ensure continuity and legal protection.
Question 5: When documenting a CVC dressing change, which observation is MOST important to include about the insertion site?
- Presence or absence of erythema, drainage, tenderness, and catheter securement integrity (Correct answer)
- Only whether a dressing was applied
- The brand of dressing used
- The nurse's personal preference for dressing type
Correct answer: Presence or absence of erythema, drainage, tenderness, and catheter securement integrity
Site assessment findings including signs of infection or complications must be recorded each time a dressing change is performed to track trends and ensure early intervention.
Question 6: Which information about IV flow rate is MOST important to document after initiating an infusion?
- Prescribed rate, actual rate set, and infusion pump ID or type used (Correct answer)
- Only the infusion start time
- The lot number of the IV bag
- The color of the tubing used
Correct answer: Prescribed rate, actual rate set, and infusion pump ID or type used
Documenting prescribed rate, actual programmed rate, and the pump used creates accountability and supports error detection if a rate discrepancy occurs.
Question 7: A peripheral IV is removed due to phlebitis. Beyond documenting removal, what must the nurse record?
- Phlebitis grade using a validated scale, site appearance, treatment initiated, and patient response (Correct answer)
- Only the time of removal
- That the charge nurse was notified
- The cost of supplies used
Correct answer: Phlebitis grade using a validated scale, site appearance, treatment initiated, and patient response
Using a validated phlebitis grading scale and documenting treatment and patient response ensures standardized assessment and supports quality improvement tracking.
VA-BC Documentation 2
When documenting PICC tip placement confirmed by chest X-ray, which anatomical landmark should be recorded as the target location?