VA-BC Maintenance and Care 5 — Questions and Answers
Question 1: Which nursing action is most effective in preventing phlebitis in a peripheral IV site?
- Using the largest gauge catheter possible for all infusions
- Rotating peripheral IV sites every 72-96 hours and assessing each site at least every 4 hours (Correct answer)
- Applying a warm compress to the IV site prophylactically before infusion
- Using extension sets to increase flow distance from the site
Correct answer: Rotating peripheral IV sites every 72-96 hours and assessing each site at least every 4 hours
Regular site rotation and frequent assessment allow early detection and prompt discontinuation before phlebitis progresses to a serious complication.
Question 2: A patient receiving IV vancomycin through a peripheral line develops a grade 2 phlebitis. What is the most appropriate next action?
- Continue the infusion but slow the rate and apply a warm compress
- Discontinue the peripheral IV, place a new one in a different site, and consider obtaining a PICC (Correct answer)
- Switch to a smaller gauge catheter in the same site to reduce irritation
- Dilute the vancomycin further and continue through the existing site
Correct answer: Discontinue the peripheral IV, place a new one in a different site, and consider obtaining a PICC
Grade 2 phlebitis with an irritant medication like vancomycin requires discontinuing the site and considering a more appropriate long-term access device such as a PICC.
Question 3: Which practice is recommended to reduce the risk of CLABSI according to the central line maintenance bundle?
- Changing the entire CVC every 72 hours
- Daily review of catheter necessity and prompt removal when no longer needed (Correct answer)
- Prophylactic antibiotic infusion through the CVC every 24 hours
- Keeping the catheter clamped between uses to reduce intraluminal contamination
Correct answer: Daily review of catheter necessity and prompt removal when no longer needed
Daily assessment and prompt removal when the CVC is no longer clinically necessary is a core component of the CLABSI prevention maintenance bundle.
Question 4: What is the correct technique for blood sampling from a CVC lumen that is infusing a continuous medication?
- Draw blood directly without stopping the infusion to save time
- Stop the infusion, wait per facility policy, discard the appropriate waste volume, then draw the sample (Correct answer)
- Draw 1 mL without waste since the continuous infusion keeps the line clear
- Switch to a different lumen and draw without stopping any infusions
Correct answer: Stop the infusion, wait per facility policy, discard the appropriate waste volume, then draw the sample
Stopping the infusion and discarding the appropriate waste volume prevents sample dilution or contamination by the infusing medication.
Question 5: Which condition is a contraindication to placing a PICC in the upper extremity on the affected side?
- History of a healed peripheral IV infiltrate on the same arm
- Mastectomy with axillary lymph node dissection on the same side (Correct answer)
- Presence of a well-healed arteriovenous fistula in the contralateral arm
- Patient preference for the dominant arm
Correct answer: Mastectomy with axillary lymph node dissection on the same side
Axillary lymph node dissection impairs lymphatic and venous drainage, significantly increasing the risk of lymphedema and thrombosis if a PICC is placed on the same side.
Question 6: A nurse is preparing to access an implanted port. After palpating the port, which gauge of non-coring (Huber) needle is most commonly used for routine access?
- 14-gauge standard IV catheter
- 19-22 gauge Huber needle (Correct answer)
- 25-gauge butterfly needle
- 18-gauge standard hypodermic needle
Correct answer: 19-22 gauge Huber needle
A 19-22 gauge Huber needle is used to access implanted ports; the non-coring design preserves the silicone septum for multiple punctures over the device's lifespan.
Question 7: During a routine assessment, a nurse notices the patient's PICC arm has developed new pitting edema and the patient reports the infusion feels 'tight.' What complication should be suspected?
- Catheter-related bloodstream infection
- Catheter occlusion from a fibrin sheath
- Extravasation or infiltration of infusate into surrounding tissue (Correct answer)
- Superior vena cava syndrome
Correct answer: Extravasation or infiltration of infusate into surrounding tissue
New edema in the extremity and patient-reported tightness during infusion are hallmark signs of infiltration or extravasation, requiring immediate cessation of the infusion.
VA-BC Maintenance and Care 5
Which nursing action is most effective in preventing phlebitis in a peripheral IV site?