VABC Patient Assessment & Evaluation 3 — Questions and Answers
Question 1: 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:
- Grade 1 — pain at site
- Grade 2 — pain with erythema
- Grade 3 — pain, erythema, streak formation, palpable cord (Correct answer)
- Grade 4 — pain, erythema, streak, palpable cord >1 inch, purulent drainage
Correct 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.
Question 2: When performing a pre-procedure assessment for ultrasound-guided PICC placement, which finding would lead you to select a different vein than the basilic?
- The basilic vein diameter measures 4 mm
- A non-compressible basilic vein with echogenic material on ultrasound (Correct answer)
- The basilic vein is located 1.5 cm deep
- The patient has visible basilic vein tortuosity on the ultrasound image
Correct 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.
Question 3: A patient undergoing assessment for midline catheter placement has a documented latex allergy. Which assessment action is MOST critical before proceeding?
- Verify the patient has an antihistamine order available
- Confirm all supplies and tourniquet materials are latex-free (Correct answer)
- Notify the physician before beginning any procedure
- Document the allergy in the patient record and proceed
Correct 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.
Question 4: Which CVAD assessment parameter should be evaluated at EVERY dressing change?
- Catheter tip position via chest X-ray
- External catheter length and comparison to insertion documentation (Correct answer)
- Serum albumin level as a marker of nutritional status
- INR to assess coagulation status
Correct 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.
Question 5: 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?
- Central line-associated bloodstream infection (CLABSI)
- Venous air embolism or pneumothorax (Correct answer)
- Catheter tip malposition in the right atrium
- Hematoma at the insertion site
Correct 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.
Question 6: 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?
- Flush forcefully with 10 mL of normal saline
- Obtain a chest X-ray to evaluate catheter position and tip location (Correct answer)
- Administer alteplase and wait 30 minutes
- Remove the Huber needle and attempt re-access
Correct 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.
Question 7: A patient with sickle cell disease requires vascular access. Which patient-specific assessment factor is MOST critical before selecting a site?
- Current pain score on the numeric rating scale
- History of prior vascular access placements and vein condition due to repeated cannulations (Correct answer)
- Hemoglobin level on most recent CBC
- Current hydration status
Correct 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.
VABC Patient Assessment & Evaluation 3
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: