VA-BC Patient Assessment 3 — Questions and Answers
Question 1: Which assessment finding in a patient with an existing PICC would MOST suggest catheter-associated deep vein thrombosis (DVT)?
- Mild redness at the insertion site
- Swelling, pain, and warmth of the entire arm (Correct answer)
- Sluggish blood return during flushing
- Low-grade fever without arm changes
Correct answer: Swelling, pain, and warmth of the entire arm
Unilateral arm swelling, pain, and warmth are classic signs of upper extremity DVT associated with catheter presence.
Question 2: When performing a pre-insertion assessment for a central line, the nurse notes a patient's platelet count is 42,000/µL. What is the appropriate next step?
- Proceed with insertion using extra pressure dressing
- Document and notify the provider before proceeding (Correct answer)
- Administer aspirin to prevent clotting complications
- Cancel the central line order entirely
Correct answer: Document and notify the provider before proceeding
Thrombocytopenia below 50,000/µL significantly increases bleeding risk and requires provider notification for risk-benefit evaluation before insertion.
Question 3: A nurse is assessing a patient for peripheral IV insertion and notes the skin over the intended vein is ecchymotic from prior attempts. What does this finding indicate?
- The vein is viable and the bruising will not affect success
- Avoid that site to reduce the risk of unsuccessful cannulation and patient discomfort (Correct answer)
- Apply warm compress and attempt in 2 minutes
- Bruising confirms the vein is superficial and easy to access
Correct answer: Avoid that site to reduce the risk of unsuccessful cannulation and patient discomfort
Ecchymotic skin over a vein indicates trauma to surrounding tissue, making venipuncture more difficult and painful; an alternate site should be selected.
Question 4: During assessment, a patient receiving IV vancomycin through a peripheral IV complains of burning and the nurse observes a red streak along the vein proximal to the insertion site. This finding is consistent with:
- Infiltration
- Chemical phlebitis (Correct answer)
- Hematoma formation
- Air embolism
Correct answer: Chemical phlebitis
A red streak along the vein with burning pain is characteristic of chemical phlebitis caused by irritating medications such as vancomycin.
Question 5: Which patient factor MOST increases the risk of catheter-related bloodstream infection (CRBSI) and should be documented during assessment?
- Age over 65
- Immunocompromised status (e.g., neutropenia, HIV) (Correct answer)
- Female sex
- Hypertension
Correct answer: Immunocompromised status (e.g., neutropenia, HIV)
Immunocompromised patients have impaired defenses against pathogens, significantly elevating their risk for CRBSI.
Question 6: A nurse assesses a patient's central venous catheter dressing and notes the dressing is damp and partially lifted at one corner. The site itself appears clean. What is the correct action?
- Reinforce the dressing with additional tape
- Perform a full dressing change using aseptic technique (Correct answer)
- Leave dressing intact as the site is clean
- Notify the provider and await orders
Correct answer: Perform a full dressing change using aseptic technique
A compromised (damp or non-intact) dressing requires immediate replacement using aseptic technique to prevent bacterial migration to the catheter site.
Question 7: During shift assessment of a patient with a tunneled CVC, the nurse notices the external catheter length is 3 cm longer than the documented length from insertion. What does this finding suggest?
- The catheter has migrated outward and tip position may have changed (Correct answer)
- Normal variation; catheter length fluctuates with breathing
- The insertion documentation was incorrect and can be ignored
- The patient has been pulling the catheter intentionally
Correct answer: The catheter has migrated outward and tip position may have changed
A change in external catheter length indicates potential catheter migration; tip position must be verified with imaging before further use.
VA-BC Patient Assessment 3
Which assessment finding in a patient with an existing PICC would MOST suggest catheter-associated deep vein thrombosis (DVT)?