Caring for Central Vascular Access Devices (CVAD) - EXAM

The nurse is unable to aspirate a blood return from the distal port of a triple-lumen CVAD and suspects an occlusion. What should the nurse do first? 1. Reposition the patient and have her raise her hand above her head; reattempt. 2. Use a smaller syringe and attempt again. 3. Insert a 10-mL syringe of preservative-free sterile normal saline and attempt to flush and aspirate rapidly and repeatedly. 4. Attach a label to the port indicating it is occluded, and use a different port of the triple- lumen CVAD.

1 (The nurse should first reposition the patient, have her take a deep breath and cough, and/or have her raise her hand above her head then reattempt. A syringe smaller than 10 mL should not be used because this could damage the catheter as a result of the high psi. Rapidly and repeatedly flushing and aspirating could cause dislodgment of a thrombus. The nurse should first attempt measures to improve patency of the port before determining it is no longer able to be used. The health care provider may order an antithrombolytic if these measures are unsuccessful.)

1. Implanted venous port 2. Tunneled central vascular access device 3. Percutaneous central vascular access device. 4. Peripherally inserted central catheter

1. Requires a noncoring needle to access device 2. Inserted first through subcutaneous tissue, then into a large vein and threaded into the distal end of the superior vena cava 3. Inserted directly through the skin into a large vein 4. Inserted in antecubital space with distal end advanced into the central circulation (A tunneled CVAD is inserted through subcutaneous tissue, then into a large vein and threaded into the distal end of the superior vena cava. It is held in place with a Dacron cuff. These catheters have single, double, or triple lumens. They carry less risk of infection than a percutaneous CVAD. An implanted infusion port rests below the skin in a subcutaneous pocket. The catheter is inserted into a large vein and threaded the superior vena cava. It requires a noncoring needle to access the device. A percutaneous central venous catheter is inserted directly through the skin into a large vein. A peripherally inserted central catheter is inserted, usually in the antecubital space with the distal end in the central circulation.)

The patient asks the nurse how frequently the dressing will have to be changed over his central vascular access device. What is the correct response by the nurse? 1. "The dressing of a vascular access device should be changed when loose, soiled, or damp, but at least every 24 hours since it is a gauze dressing." 2. "The dressing of a central vascular access device should be changed when loose, soiled, or damp, but at least every 7 days since it is a transparent occlusive dressing." 3. "The dressing only needs to be changed if it becomes loose, soiled, or damp." 4. "The dressing will be changed every 3 days or when the health care provider orders." 5. "When the initial dressing is removed, it will be replaced with a large Band-Aid."

2 (The dressing of a vascular access device should be changed when loose, soiled, or damp, but at least every 48 hours if it is gauze dressing and every 7 days if it is a transparent occlusive dressing. Band-Aids should not be used because they are not occlusive and thereby increase the risk for infection at the insertion site of the catheter.)

The nurse is sampling blood from an implanted venous port to be followed with a continuous IV infusion. Assuming all other steps are performed correctly, which of the following would require correction? 1. When cleaning over the port septum, the nurse swabs the insertion site in a horizontal plane, then a vertical plane, followed by a circular motion from the middle outward. 2. The nurse inserts the noncoring needle through the skin at a 45-degree angle and pushes down firmly until the needle hits the bottom of the portal chamber. 3. Prior to drawing the blood sample, the nurse aspirates and discards 5 mL of fluid into a biohazard container. 4. When connecting the IV, the nurse covers the secured noncoring needle and insertion site with a transparent dressing and connects the primed IV infusion tubing, regulating the rate as ordered.

2 (The noncoring needle should be inserted at a 90-degree angle. All other steps are correct)

Because the patient's central vascular access device is used intermittently for fluid administration, the nurse flushes the infusion port with a 3-mL syringe filled with heparin flush solution to maintain patency. What action made by the nurse was incorrect? 1. The nurse should always flush the CVAD with normal saline instead of heparin flush solution. 2. The nurse used a 3-mL syringe during the catheter flushing. 3. The nurse should have flushed the catheter with 2 mL of heparin flush solution instead of 3 mL. 4. The nurse flushed the catheter correctly.

2 (The nurse should avoid using a syringe less than 10 mL to minimize pressure during injection. A 3-mL syringe exerts too much psi pressure. If continuous infusion is not indicated, the nurse should heparinize the port to prevent thrombus formation by flushing with 5 mL heparin (100 units per mL or institution policy).)

The patient puts on the call light and states that his hospital gown feels wet. The nurse determines there is a break in the catheter and it is leaking. What is the initial action the nurse should take? 1. Notify the health care provider and prepare the patient to return to surgery for placement of a new central vascular access device. 2. Clamp the catheter near insertion site and place sterile gauze over break or hole. 3. Obtain blood cultures and remove catheter. 4. Have the patient cough and deep breathe; raise patient's arm over head.

2 (The nurse should first clamp the catheter between the break and the patient (usually near the insertion site) and place sterile gauze over the break or hole until repaired. Although the health care provider will be notified, if the catheter cannot be repaired, it may be removed and a new one inserted. Obtaining blood cultures and removing the catheter would be an intervention for infection at the exit site or for possible sepsis. Having the patient cough and deep breathe and raise his or her arm would be a possible intervention for an occlusion.)

The nurse is reviewing the sequence for performing a dressing change on a vascular access device. Which statement, by the nurse, indicates further instruction is needed? 1. "I will wear clean gloves to remove the previous dressing, and I will remove it in the direction the catheter was inserted." 2. "I should avoid touching the Dacron cuff in a subcutaneous tunnel because this may cause dislodgement." 3. "I will wear sterile gloves to clean and apply the new dressing." 4. "I should allow the antiseptic to dry completely before applying the transparent dressing."

2 (The nurse should palpate the Dacron cuff in the subcutaneous tunnel to determine if it is stable and in the anticipated location and that there are no signs of infection such as tenderness or warmth at the site.)

A patient with a CVAD has a suspected local or systemic infection. Which of the following actions would the nurse expect to perform at this time? 1. The nurse clamps the port, inserts a syringe, unclamps, and aspirates 5 mL of blood and sends it to the lab in a biohazard bag. The nurse flushes the port with 10 mL of normal saline and leaves the port clamped. 2. The nurse will notify the health care provider of the patient's elevated temperature and white blood cell count and prepare to administer antibiotics immediately. 3. The nurse will perform a dressing change using strict aseptic technique and assess the catheter exit site for exudate. 4. The nurse will flush the CVAD with 10 mL of normal saline, aspirate 5 mL of blood and discard, aspirate another 5 mL of blood with a second syringe and send to the lab, and flush the port with another 10 mL of normal saline.

1 (Blood cultures are often obtained both peripherally and from the vascular access device in the occurrence of a local or systemic infection. Do not flush before drawing blood for blood cultures. If blood cultures have been ordered, do not discard any blood. Use initial specimen for blood cultures. Blood cultures should be obtained before the initiation of antibiotic therapy. Changing the dressing using aseptic technique is a preventive measure but not an appropriate intervention at this time.)

Choose the supplies the nurse will need to perform a dressing change of a central vascular access device (CVAD). (Select all that apply.) 1. Sterile gloves. 2. Clean gloves. 3. Saline flush. 4. Syringes (10 mL). 5. Antimicrobial swabs. 6. Transparent or gauze dressing (and tape). 7. Mask(s).

1,2,5,6,7 (The equipment the nurse will need to perform a dressing change of a central vascular access device includes the following: sterile and clean gloves, antimicrobial swabs, transparent occlusive dressing or sterile gauze dressing/tape, and mask(s).)

1. Occlusion 2. Catheter migration 3. Infection 4. Air embolism 5. Catheter damage, breakage

1. Follow routine flushing with positive pressure; flush between medications. 2. Avoid trauma; avoid placement near site of local disease. 3. Use strict hand hygiene and aseptic technique. 4.Do not leave catheter hub open to air; engage clamps if appropriate for device. 5. Use needleless system to access port. (A preventive measure for avoiding catheter damage or breakage is to avoid having sharp objects near the catheter and to access the port with a needleless system. Routine flushing with positive pressure should be followed, as well as flushing well between medications to avoid precipitate formation or occlusion. Strict hand hygiene and aseptic technique should always be followed to avoid infection. Some health care providers prefer the application of antibiotic or antimicrobial ointment at the exit site of the catheter as a preventive measure against infection. Avoiding trauma to the catheter and avoiding placement of the catheter near a site of local disease prevent catheter migration. The nurse should not leave the catheter hub open to air and should engage clamps for catheters without valves to prevent an air embolism.)

A nurse informs the nursing assistive personnel (NAP) that the patient is to have a PICC line inserted. Which statement, if made by the NAP, indicates further instruction is needed? 1. "I should not assess the blood pressure in the arm with the PICC." 2. "The patient will be taken to surgery to have a PICC line inserted by the health care provider." 3. "A chest radiograph needs to be taken before a PICC line can be used for the first time." 4. "A PICC line can remain in place for several months as long as no complications develop."

2 (A peripherally inserted central catheter (PICC) line may be inserted by specially trained nurses in the patient's room. The arm in which a PICC or midline catheter (MLC) is in place should be avoided when assessing blood pressure. Placement of a central vascular access device must be verified before use. A PICC line is ideal when the patient requires intermediate-length venous access (from longer than 7 days to several months).)

A patient has been receiving chemotherapy via a percutaneous CVAD located in the right subclavian vein. The patient is complaining of pain and burning at the insertion site of the CVAD. The nurse notes erythema, edema, and a spongy feeling around the patient's right upper chest and neck area. Which actions would be appropriate for the nurse to take at this time? (Select all that apply.) 1. Prepare to obtain electrocardiogram. 2. Stop chemotherapy administration. 3. Administer antidote per protocol. 4. Provide emotional support. 5. Turn patient onto left side with head down.

2,3,4 (The patient is demonstrating symptoms of extravasation. Appropriate actions of the nurse include immediately stopping the vesicant administration, administering the appropriate antidote per protocol, and applying cold/warm compresses according to specific vesicant protocol. An electrocardiogram would be in order if the CVAD is placed incorrectly, resulting in cardiac dysrhythmias. Turning the patient onto the left side with head down would be appropriate if an air embolism was suspected, not for extravasation.)

Which of the following patients may benefit from a long-term vascular access device? (Select all that apply.) 1. A child undergoing surgery for a tonsillectomy. 2. A patient who is expected to require intravenous (IV) antibiotics for more than 7 days for a severe respiratory infection. 3. A patient who will be managed at home for end-stage cancer with a continuous infusion of opioids for pain. 4. A patient who is having major abdominal surgery and will require TPN administration. 5. A pregnant patient with severe nausea and vomiting requiring fluid replacement therapy. 6. A patient who requires frequent long-term phlebotomy (blood draws) in the treatment of polycythemia.

2,3,4,6 (Indications for a vascular access device include IV therapy anticipated for longer than 7 days, including transfusions, total parenteral nutrition (TPN) administration, long-term antibiotics, or continuous infusions such as opioids; infusion of vesicants or irritants, such as in chemotherapy; poor peripheral venous circulation; and frequent long-term phlebotomy. A child undergoing tonsillectomy, and a pregnant woman with nausea and vomiting would most likely only require short-term IV therapy, and therefore a long-term vascular access device would be unnecessary.)

A patient with a CVAD suddenly develops dyspnea, tachycardia, and hypotension. Into which position should the nurse place the patient? 1. Trendelenburg. 2. Lying flat on right side. 3. On left side with head down. 4. High-Fowler's.

3 (If an air embolism is suspected, place patient on left side with head down. This will help keep the air trapped in the right atrium so that it will not move in to the pulmonary circulation or the right side of the heart.)

Which nursing intervention would be appropriate if the IV of a CVAD is not infusing properly and an occlusion is suspected? 1. Kink the catheter tubing and then quickly release. 2. Use force in a pulsating manner to flush the catheter. 3. Have the patient deep breathe and cough. 4. Flush before and after medication administration; avoid flushing between medications.

3 (In the case of a possible occlusion, reposition the patient, have the patient cough and deep breathe, and raise the patient's arm over head. If the situation does not improve with these interventions, the health care provider may order a thrombolytic or solution to dissolve a precipitate. Avoid kinking the catheter to prevent occlusion. Do not flush against resistance. This could dislodge a thrombus or damage the catheter. To avoid precipitate formation, flush between medications also.)

What is the purpose of the heparin flush solution in regard to care of a vascular access device? 1. To reduce the incidence of clot formation at the exit site. 2. To prevent development of a system-wide infection. 3. To maintain patency by reducing the incidence of clot formation. 4. To prevent precipitate formation when medications are administered.

3 (The heparin flush solution is used to prevent clot formation at the catheter tip and thus prevent occlusion. The primary concern at the exit site is the development of infection. Incompatibility of medications results in precipitate formation. The catheter should be flushed well with normal saline before and after medication administration. Heparin prevents clot formation. A thrombolytic such as streptokinase may be ordered to dissolve a clot.)

Which action would be appropriate if incorrect placement of a PICC is suspected? 1. Slow all fluid administration. 2. Provide skin care using aseptic technique. 3. Administer oxygen as ordered. 4. Prepare for obtaining x-ray film.

4 (If incorrect placement is suspected, stop all fluid administration until placement is confirmed. Notify the health care provider. Orders may be received to discontinue catheter or obtain x-ray film.)

The nurse is preparing to administer continuous fluids through a central venous catheter, leaving the injection caps in place. Which step in the procedure requires correction? 1. Perform hand hygiene; apply gloves and mask(s). Prepare a syringe with 10 mL normal saline. 2. Use chlorhexidine and/or alcohol preparation swabs to cleanse injection cap. Insert needleless access device of syringe containing 10 mL normal saline, unclamp, and flush. 3. Reclamp. Connect IV tubing to injection cap of catheter using needleless access device. (IV tubing should already be flushed with IV fluid.) Tape tubing connections. 4. Flush with 10 mL heparin flush solution and clamp. Regulate IV infusion. Dispose of soiled equipment. Remove gloves and document.

4 (It is unnecessary to flush with heparin because continuous fluids are going to be administered. It would be necessary to unclamp the port before regulating the IV infusion. Hand hygiene should be performed after removing gloves.)

Which nursing diagnosis would be of most importance related to the insertion of a central vascular access device? 1. Fluid volume excess. 2. Risk for fluid volume deficit. 3. Self-care deficit. 4. Potential for infection.

4 (The priority nursing diagnosis would be potential for infection. Aseptic technique is used when inserting and providing care of a CVAD.)