VABC Documentation 3 — Questions and Answers
Question 1: When an implanted port is accessed, documentation should include all of the following EXCEPT:
- Needle gauge and length used
- Number of previous port accesses in patient's lifetime (Correct answer)
- Site appearance and patient tolerance
- Date, time, and clinician name
Correct answer: Number of previous port accesses in patient's lifetime
The total historical access count is not a required documentation element; current procedural details and patient response are what must be recorded.
Question 2: Which action best reflects accurate documentation when a central line-associated bloodstream infection (CLABSI) is suspected?
- Remove the catheter immediately without documenting
- Document signs/symptoms, notify provider, and record actions taken (Correct answer)
- Wait 24 hours before making any chart entries
- Only document after lab results confirm infection
Correct answer: Document signs/symptoms, notify provider, and record actions taken
Suspected CLABSI requires prompt documentation of clinical signs, provider notification, and all interventions in real time to support patient safety and surveillance.
Question 3: For a midline catheter insertion, which measurement must be documented to distinguish it from a PICC?
- Patient's BMI
- Catheter length inserted and external length (Correct answer)
- Type of tourniquet used
- Infusion pump rate
Correct answer: Catheter length inserted and external length
Recording the inserted and external catheter lengths confirms the tip does not extend beyond the axillary vein, distinguishing the midline from a PICC.
Question 4: A patient reports pain at a peripheral IV site. What is the FIRST documentation priority?
- Document the pain score and site assessment findings (Correct answer)
- Order new labs before charting anything
- Wait until the next nursing shift to document
- Document only if the IV is removed
Correct answer: Document the pain score and site assessment findings
An immediate record of the patient's pain complaint, pain score, and site assessment findings establishes a baseline and guides further intervention.
Question 5: Which grading scale is most commonly documented when assessing peripheral IV phlebitis?
- Glasgow Coma Scale
- Infiltration Scale
- Visual Infusion Phlebitis (VIP) Scale (Correct answer)
- Braden Scale
Correct answer: Visual Infusion Phlebitis (VIP) Scale
The Visual Infusion Phlebitis (VIP) Scale provides a standardized 0–5 grading system for documenting phlebitis severity at peripheral IV sites.
Question 6: When is it appropriate to use abbreviations in vascular access documentation?
- Any time to save charting time
- Only when abbreviations are on the facility's approved list (Correct answer)
- Never; all terms must be written in full
- Only for medication names
Correct answer: Only when abbreviations are on the facility's approved list
Only facility-approved abbreviations should be used in documentation to reduce misinterpretation and comply with accreditation standards.
Question 7: What is the primary purpose of documenting the external catheter length after each assessment of a PICC?
- To bill for catheter length used
- To detect catheter migration over time (Correct answer)
- To measure the patient's arm circumference
- To verify the brand of catheter
Correct answer: To detect catheter migration over time
Comparing the current external length to the insertion baseline helps detect inward or outward catheter migration that could affect tip position.
VABC Documentation 3
When an implanted port is accessed, documentation should include all of the following EXCEPT: