EXAM STUDY MATERIALS 8/7/2024 11:29 AM
Taylor's Clinical Nursing Skills Exam
Questions With Correct Answers
When accessing the implanted port of a central venous access device (CVAD), what action
should the nurse take to ensure the port is patent?
Aspirate a few milliliters of blood into the extension tubing to check for blood return.
Aspirate a few milliliters of blood into the syringe to check for blood return.
Open the clamp on the extension tubing and instill 3 to 5 mL of air.
Open the clamp on the extension tubing and flush with 3 to 5 mL of saline. - answer✔✔Aspirate
a few milliliters of blood into the extension tubing to check for blood return.
Rational: The nurse should check the patency of the implanted port of the CVAD by pulling back
on the syringe plunger to aspirate for blood return. Positive blood return indicates that the port is
patent. The nurse should aspirate only a few milliliters of blood and should not allow blood to
enter the syringe. Flushing the port with 3 to 5 mL of saline checks that the needle is placed
correctly. Air should not be used to flush the port as this can cause air embolism.
The nurse is flushing the implanted port of a client's central venous access device (CVAD) and
meets resistance. What should the nurse do next?
Ask the client to perform a Valsalva maneuver and place the client's arm below the heart.
Change the position of the client and lower the head of the bed.
Notify the health care provider immediately.
Check that the clamp is open, gently push down on needle, and attempt to flush again. -
answer✔✔Check that the clamp is open, gently push down on needle, and attempt to flush again.
Rational: The nurse should first check the clamp to ensure that it is open, and then gently push
down on the needle and attempt to flush again. If this does not work, the nurse could ask the
client to perform a Valsalva maneuver, change the position, or place the affected arm over the
head. The nurse could also lower or raise the head of the bed. If the port still does not flush, the
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needle should be removed and a new needle inserted. If the port does not flush this time, the
health care provider should be notified.
The nurse is accessing the implanted port of a client's central venous access device (CVAD) to
administer medications. After holding the port stable, the nurse should insert the needle into
which location?
right side of the port
left side of the port
top of the port
center of the port - answer✔✔center of the port
Rationale: The nurse should visualize the center of the port and insert the needle through the skin
into the port septum, located in the center of the port, until the needle hits the back of the port.
To function properly, the needle must be in the middle of the port and inserted to the back wall
of the port.
The nurse is flushing the implanted port of a client's central venous access device (CVAD) and
meets resistance. The nurse verifies that the clamp is open, pushes down on the needle, and, after
attempting another flush, meets continued resistance. What should the nurse do next?
Flush the port with heparin.
Notify the health care provider.
Change the access needle.
Ask the client to perform a Valsalva maneuver - answer✔✔Ask the client to perform a Valsalva
maneuver.
Rationale: If resistance is met when flushing a client's implanted port, the nurse should first
verify the clamp is open, push down on the needle, and attempt to flush again. If continued
resistance is met, the nurse should ask the client to perform a Valsalva maneuver, change
positions, or place the affected arm over the head. The access needle would not be changed until
other remedies have been attempted. Flushing the port with heparin may prevent a port from
clotting but will not resolve a clot. The health care provider should be notified after all remedies
have been attempted; the health care provider may give a prescription for a clot-dissolving agent.
The nurse is unable to flush the implanted port of a client's central venous access device
(CVAD), despite repeated efforts at repositioning the client. Which action by the nurse is most
appropriate?
Place the client's arm below the level of the heart and attempt to flush the port.
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Re-access the port with a new needle, according to facility policy.
Contact the health care provider for further prescription.
Increase pressure used, gradually, while flushing until the problem resolves. - answer✔✔Re-
access the port with a new needle, according to facility policy.
Rationale: If resistance is met when flushing the client's implanted port and the nurse has
attempted all remedies including changing client position, the nurse should re-access the port
with a new needle and attempt to flush again, according to facility policy. After the port has been
re-accessed and the nurse is still unable to flush the port, the nurse should contact the health care
provider for a further prescription. Placing the client's arm below the level of the heart will not
remedy the problem. Increasing pressure or "forcing" the flush may result in damage to the port
and should not be attempted.
A nurse is administering blood products to a client via an implanted port central venous access
device (CVAD). What technique should the nurse use to locate the site of the port?
Auscultation
Observation
Percussion
palpation - answer✔✔palpation
Rationale: The nurse should put on clean gloves and palpate the location of the port. Because the
port is implanted, observation alone should not locate the site. Percussion and auscultation would
not be effective, because there are no associated sounds that should enable the nurse to locate the
port.
After accessing the implanted port of a client's central venous access device (CVAD), what
action does the nurse take to prevent air embolism?
Clamp the extension tubing
Start the intravenous infusion
Flush the extension tubing with normal saline
Flush the extension tubing with heparin - answer✔✔Clamp the extension tubing
Rationale: The nurse removes the syringe and clamps the extension tubing to prevent air from
entering the CVAD, which may cause an air embolism. The tubing is flushed with normal saline
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prior to this step. Flushing the line with heparin helps to prevent clotting and ensures patency of
the line. A heparin flush is not used if an IV fluid infusion is running; however, starting the
infusion will not prevent an air embolism.
A nurse is preparing to access the implanted port of a client's central venous access device
(CVAD). The nurse asks the client to turn the head away from the access site, but the client is
unable to do so. What is the next action by the nurse?
Place a mask on the client.
Urge the client not to cough.
Ask the client to hold the breath.
Tell the client to look away. - answer✔✔Place a mask on the client.
Rationale: Turning the head away from the access site helps to deter the spread of
microorganisms. If a client is unable to turn the head away from the site, the nurse should place a
mask on the client to help deter the spread of microorganisms. Masks may also be necessary
based on facility policy. Asking the client to hold the breath, look away, or avoid coughing
would not be effective in preventing the spread of microorganisms.
The nurse is caring for a client who has an implanted port central venous access device (CVAD)
and needs to have an intravenous (IV) solution infused. The nurse has appropriately prepared the
solution, the infusion set, and the port site. Just before inserting the access needle, the nurse notes
that it is bent at an angle. Which action is correct?
Obtain a new access needle and report the flawed needle to the facility's risk manager.
Insert the needle through the skin into the center of the infusion port and begin the infusion.
Insert the needle through the skin close to the edge of the port, and then use the rigid port side to
brace the needle while straightening it.
Using sterile forceps, gently straighten the needle, and then insert it into the center of the
infusion port. - answer✔✔Insert the needle through the skin into the center of the infusion port
and begin the infusion.
Rationale: Implanted port CVADs are accessed with a specially-designed, angled needle; the
nurse should not attempt to straighten it or replace it.
The nurse uses a small amount of sterile solution from a large, multiuse bottle to moisten gauze
in a sterile field. What technique does the nurse use?
Pour the liquid into the palm of a sterilely gloved hand for use.
