Caring for Central Vascular Access Devices (CVAD) -
EXAM 2022 with complete solution
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.)
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.)
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.)
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.)
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.
EXAM 2022 with complete solution
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.)
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.)
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.)
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.)
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.
