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's tunneled CVC insertion site shows a small amount of clear serous drainage at the exit site that began 3 days after placement. Which assessment action is MOST appropriate?
Answer: Document as expected post-procedure healing and assess for signs of infection at each dressing change
Small amounts of clear serous drainage within the first few days post-tunneled catheter insertion are a normal healing response; ongoing assessment for infection signs is appropriate.
When using the DIVA (Difficult Intravenous Access) score to assess a patient, which combination of factors results in the highest risk classification?
Answer: Non-visible and non-palpable veins, history of multiple failed IV attempts, IV drug use history
Non-visible, non-palpable veins combined with prior failed attempts and IV drug use history yield the highest DIVA score, indicating greatest difficulty.
A post-mastectomy patient requires vascular access. Which assessment finding from the history should most directly guide site selection?
Answer: Whether an axillary lymph node dissection was performed on one or both sides
Axillary lymph node dissection increases risk of lymphedema, making that ipsilateral arm contraindicated for vascular access.
When assessing a pediatric patient for peripheral IV placement, which vein site should be AVOIDED in neonates unless no other option exists?
Answer: Footveins distal to the ankle
Foot veins distal to the ankle pose risk of tissue necrosis and should be avoided in neonates unless no other site is available due to poor collateral circulation.
A patient with a peripherally inserted central catheter (PICC) presents with a swollen, warm, tender arm. Duplex ultrasound confirms upper extremity DVT. Which assessment should the nurse complete NEXT?
Answer: Assess catheter functionality, treatment indication, and risk-benefit of continued use versus removal
Clinical decision-making regarding PICC removal in the setting of catheter-related thrombosis requires assessment of catheter necessity, function, and patient-specific risk-benefit analysis.
Which finding during assessment of a patient with an implanted venous port would indicate the device requires IMMEDIATE discontinuation of infusion?
Answer: Swelling and burning at the port site during infusion suggesting extravasation
Swelling and burning at the port site during infusion are hallmark signs of extravasation, which requires immediate cessation of infusion to prevent tissue damage.
A patient assessment reveals a hemodialysis fistula in the left forearm. Which vascular access action is contraindicated in that arm?
Answer: Venipuncture, IV placement, and blood pressure measurement in that arm
Any compression or cannulation of an AV fistula arm — including blood pressure cuffs, venipuncture, or IV placement — is contraindicated to protect the fistula.