Advanced skills exam 2

A client has an implanted infusion port for chemotherapy. How often will the port need to be flushed when not accessed? A.) once per month B.) once every 3 months C.) every day D.) once per week

A

Describe 3 benefits of a semipermeable dressing

Allows visual inspection Secures the catheter Requires less frequent changes

how often would the nurse change the noncoring needle for a patient with an accessed implanted port?

5-7 days

What volume of blood should be wasted when obtaining a blood sample from an implanted port?

5-10 mL or per facility policy

The nurse knows that which of the following patients would be a likely candidate for a PICC line? A.) A 70 year old who will need 10 days of IV antibiotics B.) A 90 year old who will need 5 days of IV antibiotics C.) A 42 year old who will need frequent infusions of chemo D.) A 36 year old who will need two units of packed RBCs

A If 7 days or more go with a PICC less than 7 days go with peripheral IV

The nurse has an order to remove a PICC line. Prior to removal, the nurse assesses the site for signs of infection, including swelling, drainage, redness, and inflammation. Upon removal, the nurse meets resistance. What steps should the nurse implement next? Select all that apply A.) Instruct the client to relax B.) Instruct the client to raise their arm C.) Reattempt after 5 to 10 minutes D.) Stop the procedure E.) Apply a cool compress above the insertion site

A, B, D

Your patient has a blood type known as the universal recipient. What is their blood type?

AB+

Identify 2 complications that can occur during central line insertion and nursing actions for each.

Air embolism - left lateral decubitus or left Trendelenburg position to trap the air in the right atrium, apply oxygen Nerve injury - assess for pupil constriction with light reaction and upper eyelid drooping

A client recently had an implanted port placed yesterday. What is a nursing consideration prior to accessing the implanted port?

Consider administering a local anesthetic When the needle has penetrated the skin, the patient may feel pressure and discomfort. Eventually, the skin over the port will become desensitized from frequent needle punctures

Your patient with a central line suddenly complains of shortness of breath, confusion, and disorientation.What are your first steps?

Apply oxygen Position on left side Trendelenburg Assess for breath sounds Call for help

Which nursing intervention would be a safety priority when administering medications through an implanted port?

Assess patency before administering medications

The client just had an implanted port placed. When can the port be used? A.) After 72 hours B.) Immediately after placement has been verified C.) After the skin and tissue have fully healed D.) After seven days

B

The nurse ensures that the clamp is closed on the central line prior to changing the needless connector for what purpose? A.) Prevent catheter migration B.) Reduce risk of air emboli C.) Reduce risk of thrombosis D.) Prevent infection

B

Which nursing intervention would be the safety priority when administering medication through an implanted port? A.) Use 10mL of normal saline before and after medication admsintiration B.)Assess patency and adequate placement before administering medications C.)Use 20 mL or normal saline followed by 2.5 mL of Heparin (100units/mL) D.)Use of barrel syringes

B

The nurse has just removed a client's PICC. After removal, what should be documented? Select all that apply A.). That the dressing was removed B.) The integrity of the catheter C.) The length of the catheter D.) How the client tolerated the procedure

B, C, D

A client has a peripheral IV catheter infusing normal saline at 100mL/hr. The nurse notes swelling and coolness at the insertion site. What is the priority intervention of the nurse? A.) Call the provider B.) Slow the infusion rate C.) Saline lock the IV D.) Stop the infusion

D

What is the ideal vein for PICC line placement?

Basilic

Your patient is having a PICC line placed this afternoon. What vein would you expect to be used in this procedure for best results?

Basilic vein

A client will be having a PICC inserted today for prolonged antibiotic therapy. The nurse is providing education on PICC placement and discusses that the possible insertion sites include which of the following?

Basilic vein Brachial vein Cephalic vein

Under what circumstances should central venous catheters be flushed?

Before and after medication of administration After blood sampling Upon discontinuation of an infusion

Describe contraindications to obtaining a blood sample from a central line.

Blood cultures x2 (2 different sites must be used) When fluids or medications are currently infusing(need to turn off for 10 minute or per facility policy)

After an insertion of a central venous catheter through the left subclavian vein, a client reports chest pain and dyspnea and has decreased breath sounds on the left side. Which action would the nurse take first? A.) call rapid response B.) auscultate breath sounds C.) apply oxygen as needed D.) place the pt in prone position

C

The nurse has just removed the central line dressing on a client. The nurse notes that there is adhesive remaining on the patient's skin. What is the next action of the nurse? A.) Clean the site with a chlorohexidine cleanser B.). Proceed with applying a new sterile dressing C.) Use an acetone-free adhesive remover to remove adhesive from the client's skin D.)Apply a new chlorohexidine impregnated spong

C

The nurse is caring for a client who has an implanted port. How often would the nurse change the noncoring needle? A.) every 3 days B.) every two weeks C.) every 7 days D.) every month

C

The nurse is preparing to access the client's implanted port. What nursing intervention will reduce the risk of infection? A.) Flush the extension tubing with preservative free normal saline B.) Insert the noncoring needle perpendicular to the skin C.) Assemble supplies on a sterile field D.) Wear clean gloves while accessing the port

C

Your client has a central line and they develop sudden onset of chest pain, dyspnea, and hypotension. The nurse suspects what complication is occurring? A.) Catheter migration B.) Deep vein thrombosis C.) Air embolism D.) Infection

C

A patient just had a PICC removed and develops signs of an air embolism. The nurse must take what action? Select all that apply A.) Place the client in a High Fowlers position B.) Have the client take a deep breath C.) Apply oxygen D.) Place client in a left Trendelenburg position E.) Instruct the client to perform the Valsalva maneuver

C, D

How often should a semipermeable dressing be changed covering an implanted port? A.) every 24 hours B.). every 5 days C.) every 2 days D.) every 7 days

D

When a client requires IV therapy, catheter flushing, or blood withdrawal, an implanted port is accessed using a noncoring needle. What is unique about this needle? A.) It is designed to access the septum on numerous occasions B.) It removes the risk of air emboli C.) It is longer than most needles D.) It has a deflected point, which slices the port's septum

D

which procedure is used to verify placement of a newly inserted central venous access device?

Chest X-ray

What is the first action the nurse should take if the needleless connector becomes disconnected from the lumen?

Clamp the lumen

Identify 4 pre-procedural assessments for central line dressing changes.

Date of last dressing change Measure external length of catheter for migration Assess skin-catheter junction sites for bleeding, redness, swelling, and drainage Pain

What is the primary purpose for flushing a central venous catheter after a blood draw?

Decrease the risk of thrombotic catheter occlusion

You are flushing a central line and it does not flush.What are some possible nursing interventions for this?

Ensure clamps are open Assess for catheter occlusion (kinks, patient position) Extend or raise patient's arm overhead If occlusion is due to thrombosis, a provider will need to order a thrombolytic

How often should the non-coring needle of an implanted port be replaced?

Every 7 days

What amount of fluid should be flushed to reduce the risk of catheter damage when flushing a central venous catheter?

Flushing with at least 10mL of normal saline or 2x the volume within the system

Identify 4 nursing strategies to prevent catheter related blood stream infections.

Handwashing Dressing changes no more than every 96 hours, no later than 7 days (unless otherwise indicated) Scrub the hub appropriately Change needleless connectors as needed Don't access more than necessary

Describe 2 steps the nurse should take to prevent infection when changing a central venous catheter dressing

Have the patient wear a mask or turn head to side Have the practitioner wear a mask Utilize sterile technique Clean beginning at the site of insertion and move away Allow to dry completely

A client had an implanted port placed early this morning. when can the port be used?

Immediately after placement has been verified.

Your patient was recently diagnosed with cancer and will be receiving chemotherapy over the next 4 months, what central venous catheter would you expect to be placed?

Implanted Port

Describe 2 advantages of your patient receiving an implanted port over a tunneled central venous catheter

Improved body image (low visibility of port) Patient comfort Local catheter site care and dressing not needed when not in use

Identify 4 potential complications of vascular access devices and the nursing actions for each. complication.

Infection - wash hands, perform dressing changes and cap changes per agency policy Nerve injury with PICC insertion DVT - SCDs/ambulation, ensure prophylactic anti thrombosis medication Air embolism - ensure the clamp is clamped prior to removing needleless connector, flush new needleless connector with saline before attaching Inadvertent dislodgement - patient and staff education

What amount of time should pass following the placement of an implanted port?

It can be used immediately

Describe 3 pieces of education you should provide your patient with a central venous catheter

Keep clamps closed when it is exposed to air Cover the site when bathing or showering Avoid sports Keep sharp objects away from the catheter to prevent blood backflow or air embolism Avoid swimming Notify your provider of any upper extremity soreness

Name 3 locations an IV should not be inserted into for an adult patient

Legs Feet Scalp Restricted extremity

Which of the following are indications for implanted port use?

Long term IV therapy Intermittent vascular access Frequent CT scans

List the indications a central line might be inserted

Long term abx therapy Frequent lab draws No peripheral access TPN Trauma

Describe 4 reasons your patient may have a PICC line placed instead of a peripheral IV.

Long term antibiotics - infusions can be frequent, prevents need for new IV site each session Frequent lab draws No peripheral access - some patient have veins that are not easy to access High osmolarity solutions TPN Trauma

Your patient is receiving frequent antibiotics for 19 days and is a difficult IV start. What CVC would you expect to be inserted?

PICC Line

Upon removal of a PICC, what should the nurse instruct their client to do?

Perform the Valsalva maneuver

What step should the nurse take if the patient begins to develop shortness of breath, coughing, and cyanosis with a central venous catheter?

Place the patient in Trendelenburg

Outline nursing actions required when an airembolism is suspected.

Position on left side or Trendelenburg Apply oxygen via mask Call for help

When hanging a piggy back infusion, which bag of fluids should be lower using the blue hook?

Primary bag of fluids should be lower using the blue hook

Describe the steps to administering a medication IV push that is not compatible with the running solution

Stop the pump Flush with normal saline Administer the medication Flush with normal saline Restart the pump

True or False: Access an implanted port requires sterile technique

TRUE!

What steps should the nurse take when removing a PICC line and resistance is met?

Tell the patient to relax Stop the removal Apply a warm compress Reattempt in about 30 minutes

The nurse is preparing to access the port of a patient with a high BMI. What should the nurse do differently given this information?

Utilize a longer non-coring needle

What is the best way to prevent an IV on an infant from becoming dislodged?

Utilized a joint stabilization device along with your semi-transparent dressing

Implanted Ports:

a surgically tunneled port under the skin that is accessed with a non-coring needle o Long term use

A nurse is preparing to access the client's implanted port. What nursing intervention will reduce the risk of infection?

assemble supplies on a sterile field

what teaching would you provide to your patient following PICC placement?

cover it in the shower report any pain, redness, swelling, sob, heart palpitations no baths or swimming ensure clamps are closed to avoid air embolism avoid sports avoid sharp objects

In which of the following situations should you flush a port?

daily, if port is access and no solution is infusing after each infusion before each infusion after blood sampling

A client has an accessed implanted port without a continuous infusion. how often will the port need to be flushed?

every day

True or false: Noncoring needles only come in one length and gauge.

false

Upon completing a port infusion, the nurse has an order to deaccess. what step should the nurse take before deaccessing?

flush with normal saline, at least twice the internal volume.

What are the advantages of an implantable port vs PICC

improved body image local catheter site care and dressing changes not needed patient comfort

Your patient has an implantable port, which of the following are possible complications?

infection skin breakdown infiltration/catheter migration vessel wall puncture

Tunneled:

is a surgically inserted catheter that's tunneled under the skin and inserted by way of the subclavian or internal jugular vein until its tip lies in the superior vena cava. Used for administering IV fluids, intermittent IV medications, blood products, and parenteral nutrition. long term use (weeks to months)

PICC Line:

is inserted in a large peripheral vein such as the cephalic or basilica vein until it is advanced until the tip rests in the distal superior vena cava o Short to intermediate use

When a client with an implanted port is accessed for care using a noncoring needle. what is unique about the needle?

it has a deflected point, which slices the port's self sealing septum.

Non-tunneled:

percutaneously inserted into central veins, typically in emergent situation so Usually less than 3 weeks

Why do we flush a central line with a full 10 ml?

prevent catheter damage

what is the most appropriate action when selecting a noncoring needle for a patient with excess adipose tissue on the chest?

select a longer needle to prevent accidental dislodgement

What are nursing strategies used to prevent catheter related blood stream infection?

sterile technique with dressing changes wash hands pt wears a mask impregnated sponge antimicrobial cleanser check site each shift nurse wear mask dressing changes: no earlier than 5 days and not after 7 days. change needleless connector when you see blood don't access needless connector more than needed

True or false: a noncoring needle needs to be flushed prior to accessing the implanted port.

true

True or false: sterile technique should be followed when accessing an implanted port?

true