VABC Patient Assessment & Evaluation 2 — Questions and Answers
Question 1: 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?
- Fever above 38.5°C
- Pitting edema of the ipsilateral arm with visible collateral veins (Correct answer)
- Redness at the insertion site
- Decreased blood pressure in the affected arm
Correct 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.
Question 2: When assessing a patient's vein quality for peripheral IV placement, which characteristic indicates a vein is most suitable for cannulation?
- Feels soft, bouncy, and refills after pressure is released (Correct answer)
- Appears blue and is highly visible without palpation
- Is located in the antecubital fossa for easy access
- Has been previously cannulated within the last 72 hours
Correct 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.
Question 3: Which Braden Scale score indicates a patient is at HIGH risk for pressure injury and should factor into vascular access site selection?
- Score of 19-23
- Score of 15-18
- Score of 13-14
- Score of 12 or below (Correct answer)
Correct 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.
Question 4: 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?
- BUN of 45 mg/dL
- Serum potassium of 6.8 mEq/L (Correct answer)
- Creatinine of 4.2 mg/dL
- Phosphorus of 5.5 mg/dL
Correct 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.
Question 5: 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?
- Ask about current medication allergies
- Determine if the port is still in place and functional (Correct answer)
- Assess current nutritional status
- Review current chemotherapy protocols
Correct 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.
Question 6: A patient with a BMI of 42 requires peripheral IV access. Which assessment approach is BEST to locate a suitable vein?
- Use a blood pressure cuff as a tourniquet and rely on visual identification
- Palpate deeply along the antecubital fossa and forearm, using ultrasound if no vein is found (Correct answer)
- Immediately request a central line due to obesity
- Attempt multiple venipunctures systematically until a vein is accessed
Correct 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.
Question 7: Which assessment finding in a patient receiving TPN through a CVAD is MOST indicative of a possible catheter occlusion?
- Blood glucose of 220 mg/dL
- Inability to aspirate blood return with sluggish or absent infusion flow (Correct answer)
- Mild fever of 37.8°C
- Elevated triglycerides on morning labs
Correct 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.
VABC Patient Assessment & Evaluation 2
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?