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 receiving vancomycin through a peripheral IV develops redness and streaking along the vein proximal to the insertion site. Using the INS Phlebitis Scale, this finding is BEST classified as:
Answer: Grade 3 — pain, erythema, streak formation, palpable cord
Grade 3 phlebitis is defined by pain, erythema, streak formation above the site, and a palpable venous cord.
When performing a pre-procedure assessment for ultrasound-guided PICC placement, which finding would lead you to select a different vein than the basilic?
Answer: A non-compressible basilic vein with echogenic material on ultrasound
A non-compressible vein with internal echogenic material is diagnostic of existing thrombosis, contraindicating catheter placement in that vessel.
A patient undergoing assessment for midline catheter placement has a documented latex allergy. Which assessment action is MOST critical before proceeding?
Answer: Confirm all supplies and tourniquet materials are latex-free
Ensuring all equipment including tourniquets, gloves, and supplies are latex-free is essential to prevent anaphylaxis in latex-allergic patients.
Which CVAD assessment parameter should be evaluated at EVERY dressing change?
Answer: External catheter length and comparison to insertion documentation
Measuring and comparing the external catheter length at every dressing change detects migration or dislodgement early.
A patient with a newly placed CVC reports sudden onset of sharp chest pain and dyspnea within 30 minutes of insertion. Which complication should the vascular access nurse assess for FIRST?
Answer: Venous air embolism or pneumothorax
Sudden chest pain and dyspnea immediately post-CVC insertion are classic signs of pneumothorax or air embolism, both life-threatening emergencies.
During assessment of a patient's implanted port, the nurse attempts to access the port but meets resistance and cannot aspirate blood. After repositioning the patient's arm and having them cough, there is still no blood return. What is the NEXT assessment step?
Answer: Obtain a chest X-ray to evaluate catheter position and tip location
When position changes fail to restore blood return, imaging is indicated to rule out catheter malposition, fibrin sheath, or tip migration before any intervention.
A patient with sickle cell disease requires vascular access. Which patient-specific assessment factor is MOST critical before selecting a site?
Answer: History of prior vascular access placements and vein condition due to repeated cannulations
Patients with sickle cell disease often have significantly compromised venous access due to years of repeated cannulations, making historical vein mapping essential.