Patient Assessment & Evaluation Flashcards
7 cards from real VABC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Patient Assessment & Evaluation flashcards as text
A patient reports a PICC line was placed 3 days ago but now has pain and swelling along the upper arm. Which assessment finding would most strongly suggest catheter-related thrombosis?
Answer: Pitting edema of the ipsilateral arm with visible collateral veins
Pitting edema with visible collateral veins indicates venous outflow obstruction consistent with upper extremity DVT.
When assessing a patient's vein quality for peripheral IV placement, which characteristic indicates a vein is most suitable for cannulation?
Answer: Feels soft, bouncy, and refills after pressure is released
A soft, bouncy vein that refills after compression indicates patent, healthy venous structure ideal for cannulation.
Which Braden Scale score indicates a patient is at HIGH risk for pressure injury and should factor into vascular access site selection?
Answer: Score of 12 or below
A Braden Scale score of 12 or below indicates high risk for pressure injury, requiring careful site selection to avoid further skin compromise.
A nurse is assessing a patient with end-stage renal disease (ESRD) prior to vascular access placement. Which assessment finding should prompt immediate escalation before proceeding?
Answer: Serum potassium of 6.8 mEq/L
A serum potassium of 6.8 mEq/L indicates severe hyperkalemia, which poses immediate cardiac risk requiring physician notification before any invasive procedure.
During initial assessment for vascular access, a patient states they received chemotherapy through a port 5 years ago. What is the MOST important follow-up assessment?
Answer: Determine if the port is still in place and functional
Determining whether the port remains implanted and its current status is critical to avoid redundant device placement or complications with an existing device.
A patient with a BMI of 42 requires peripheral IV access. Which assessment approach is BEST to locate a suitable vein?
Answer: Palpate deeply along the antecubital fossa and forearm, using ultrasound if no vein is found
Deep palpation combined with ultrasound guidance is the evidence-based approach for patients with difficult venous access due to obesity.
Which assessment finding in a patient receiving TPN through a CVAD is MOST indicative of a possible catheter occlusion?
Answer: Inability to aspirate blood return with sluggish or absent infusion flow
Absent blood return combined with sluggish or no infusion flow is the classic presentation of catheter occlusion requiring assessment and intervention.