VABC Documentation 2 — Questions and Answers
Question 1: When documenting a PICC insertion, which anatomical landmark must be recorded to confirm tip position?
- Antecubital fossa entry site
- Cavoatrial junction or lower third of superior vena cava (Correct answer)
- Subclavian vein junction
- Right atrium
Correct answer: Cavoatrial junction or lower third of superior vena cava
PICC tip position must be documented as residing at the cavoatrial junction or the lower third of the SVC for safe central venous infusion.
Question 2: Which element is REQUIRED when documenting a failed venipuncture attempt?
- Patient's insurance information
- Site attempted, gauge used, and reason for failure (Correct answer)
- Name of the charge nurse on duty
- Patient's most recent lab values
Correct answer: Site attempted, gauge used, and reason for failure
Documentation of a failed attempt must include the anatomical site, catheter gauge, and the reason the attempt was unsuccessful.
Question 3: How should an infusion nurse document verbal consent for a peripheral IV insertion when a written consent form is not required?
- No documentation is needed for verbal consent
- Note in the medical record that verbal consent was obtained (Correct answer)
- Have the charge nurse co-sign the order
- Document only if the patient is a minor
Correct answer: Note in the medical record that verbal consent was obtained
Verbal consent should be noted in the medical record to demonstrate that the patient was informed and agreed to the procedure.
Question 4: When documenting catheter flushing, which information is MOST essential to include?
- Brand name of the syringe used
- Type and volume of flush solution and patient response (Correct answer)
- Time the order was received
- Physician's pager number
Correct answer: Type and volume of flush solution and patient response
Documentation of flushing must capture the flush solution type (e.g., normal saline), volume used, and the patient's response to ensure accountability.
Question 5: A patient's central venous catheter dressing is changed. Which detail is LEAST necessary in the dressing change documentation?
- Date and time of dressing change
- Condition of the insertion site
- Type of dressing applied
- Color of the patient's hospital gown (Correct answer)
Correct answer: Color of the patient's hospital gown
The patient's gown color has no clinical relevance; site condition, dressing type, and timing are all required elements.
Question 6: What does documenting 'blood return confirmed' prior to infusion demonstrate?
- That the catheter is properly sized
- That patency and correct catheter placement were verified (Correct answer)
- That the infusion pump is calibrated
- That the patient has adequate hemoglobin
Correct answer: That patency and correct catheter placement were verified
Documenting blood return confirms catheter patency and suggests proper intravascular placement before initiating infusion.
Question 7: Under HIPAA, vascular access documentation shared with another care team member must be:
- Sent via personal email for speed
- Shared only through secure, authorized channels for treatment purposes (Correct answer)
- Printed and left at the nurses' station
- Verbally communicated without written record
Correct answer: Shared only through secure, authorized channels for treatment purposes
HIPAA requires that protected health information, including vascular access records, be shared only through secure, authorized systems for legitimate treatment purposes.
VABC Documentation 2
When documenting a PICC insertion, which anatomical landmark must be recorded to confirm tip position?