VABC Patient Assessment & Evaluation 4 — Questions and Answers
Question 1: 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?
- Culture the drainage and notify the physician of suspected infection
- Document as expected post-procedure healing and assess for signs of infection at each dressing change (Correct answer)
- Remove the catheter immediately given drainage is abnormal
- Apply antimicrobial ointment without further assessment
Correct 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.
Question 2: When using the DIVA (Difficult Intravenous Access) score to assess a patient, which combination of factors results in the highest risk classification?
- Visible veins, no prior IV access issues, normal BMI
- Non-visible and non-palpable veins, history of multiple failed IV attempts, IV drug use history (Correct answer)
- Single prior failed IV attempt, slightly overweight, visible but small veins
- Requires frequent blood draws, history of chemotherapy, moderate obesity
Correct 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.
Question 3: A post-mastectomy patient requires vascular access. Which assessment finding from the history should most directly guide site selection?
- The type of chemotherapy agents previously received
- Whether an axillary lymph node dissection was performed on one or both sides (Correct answer)
- The date of the most recent mammogram
- Current upper extremity range of motion
Correct 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.
Question 4: When assessing a pediatric patient for peripheral IV placement, which vein site should be AVOIDED in neonates unless no other option exists?
- Dorsal hand veins
- Scalp veins
- Antecubital veins
- Footveins distal to the ankle (Correct answer)
Correct 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.
Question 5: 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?
- Remove the PICC immediately per standing orders
- Assess catheter functionality, treatment indication, and risk-benefit of continued use versus removal (Correct answer)
- Apply a warm compress and elevate the arm
- Administer anticoagulation and continue PICC use
Correct 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.
Question 6: Which finding during assessment of a patient with an implanted venous port would indicate the device requires IMMEDIATE discontinuation of infusion?
- Patient reports mild discomfort with flushing
- Swelling and burning at the port site during infusion suggesting extravasation (Correct answer)
- Sluggish blood return requiring patient repositioning
- Site has slight tenderness to palpation at the port reservoir
Correct 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.
Question 7: A patient assessment reveals a hemodialysis fistula in the left forearm. Which vascular access action is contraindicated in that arm?
- Blood pressure measurement only
- Venipuncture, IV placement, and blood pressure measurement in that arm (Correct answer)
- Ultrasound assessment for vein mapping
- Palpation of the fistula for thrill
- Venipuncture, IV placement, and blood pressure measurement in that arm
Correct 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.
VABC Patient Assessment & Evaluation 4
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?