VABC Patient Assessment & Evaluation 5 — Questions and Answers
Question 1: A patient on warfarin with an INR of 3.8 requires urgent central venous access. Which assessment information is MOST critical when selecting the insertion site?
- Whether the patient has eaten within the last 4 hours
- The insertion site's compressibility in case of arterial puncture (Correct answer)
- The patient's most recent echocardiogram results
- The patient's height and weight for catheter sizing
Correct answer: The insertion site's compressibility in case of arterial puncture
In anticoagulated patients, choosing a compressible site (subclavian is non-compressible) is critical to allow hemostasis in case of inadvertent arterial puncture.
Question 2: During a vascular access assessment, the nurse notes that a patient receiving peripheral parenteral nutrition (PPN) has a VAS (Visual Analog Scale) pain rating of 4/10 at the IV site. What is the PRIORITY assessment?
- Administer analgesic medication per order
- Inspect and palpate the IV site for signs of infiltration or phlebitis (Correct answer)
- Slow the infusion rate and reassess in one hour
- Obtain a physician order to convert to central venous access
Correct answer: Inspect and palpate the IV site for signs of infiltration or phlebitis
Pain at a PPN infusion site warrants immediate site inspection and palpation to rule out infiltration or phlebitis before any other intervention.
Question 3: A patient with a history of superior vena cava (SVC) syndrome is referred for long-term venous access. Which assessment finding would most directly influence the access strategy?
- Current performance status and ambulatory ability
- Degree of SVC stenosis or occlusion and availability of alternative venous pathways (Correct answer)
- Current oral medication regimen
- Presence of a pacemaker or implantable defibrillator
Correct answer: Degree of SVC stenosis or occlusion and availability of alternative venous pathways
The degree of SVC obstruction determines whether standard PICC or CVC placement is feasible or if alternative routes such as femoral access must be considered.
Question 4: When assessing a patient for a midline catheter versus a PICC, which clinical factor most clearly favors a PICC over a midline?
- Therapy duration expected to be 5–7 days
- Need for infusion of a vesicant chemotherapy agent (Correct answer)
- Patient preference for upper arm placement
- Adequate peripheral venous access already present
Correct answer: Need for infusion of a vesicant chemotherapy agent
Vesicant chemotherapy requires central venous tip placement to ensure adequate hemodilution, making a PICC necessary over a midline catheter.
Question 5: A patient's nursing history reveals previous bilateral subclavian vein thromboses. Which vascular access assessment finding is MOST important to obtain before selecting an alternative central access route?
- Current platelet count
- Patency of jugular, femoral, or translumbar venous alternatives via imaging review (Correct answer)
- Presence of prior scarring at potential insertion sites
- Most recent chest X-ray for baseline comparison
Correct answer: Patency of jugular, femoral, or translumbar venous alternatives via imaging review
Bilateral subclavian thromboses eliminate those routes; venous mapping of remaining patent vessels is essential before selecting an alternative central access site.
Question 6: A patient with congestive heart failure (CHF) and an ejection fraction of 20% requires central venous access for inotropic therapy. During assessment, the nurse notes prominent jugular venous distension (JVD) to the jaw. This finding indicates:
- The internal jugular vein will be easily cannulated due to distension
- Markedly elevated central venous pressure requiring physician notification before proceeding (Correct answer)
- Normal finding in a patient with CHF receiving diuretics
- Correct catheter positioning if a CVC is already in place
Correct answer: Markedly elevated central venous pressure requiring physician notification before proceeding
JVD to the jaw reflects severely elevated CVP and hemodynamic instability, which must be communicated to the physician before invasive procedures.
Question 7: An assessment reveals that a patient has a peripherally inserted catheter with a 4 cm external length, whereas the insertion note documents an external length of 1 cm at placement. What is the CORRECT interpretation and action?
- The catheter has migrated outward 3 cm; do not use until tip position is confirmed by imaging (Correct answer)
- The measurement difference is within normal variation; proceed with planned infusion
- The catheter tip has advanced deeper; increase the infusion rate accordingly
- Retract the catheter 3 cm to restore original position without imaging
Correct answer: The catheter has migrated outward 3 cm; do not use until tip position is confirmed by imaging
A 3 cm increase in external length indicates catheter migration out of the vessel, and tip position must be confirmed by imaging before the device is used.
VABC Patient Assessment & Evaluation 5
A patient on warfarin with an INR of 3.8 requires urgent central venous access.
Which assessment information is MOST critical when selecting the insertion site?