Exam (elaborations)
Taylor-s Clinical Nursing Skills Block 3 (1).
Taylor-s Clinical Nursing Skills Block 3 (1).
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Taylor's Clinical Nursing Skills Block 3When 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. - CORRECT
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. -
CORRECT 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 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 - CORRECT 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 - CORRECT 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.
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. - CORRECT
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 - CORRECT 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 - CORRECT 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
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. - CORRECT 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. - CORRECT 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.
Pour the liquid into a sterile container within the sterile field.
Pour the liquid onto gauze on the sterile field until the gauze is moist.
Pour the liquid into the cap of the bottle and dip the gauze as needed. - CORRECT
ANSWER-Pour the liquid into a sterile container within the sterile field.
Rationale: The liquid from a large container is poured into a sterile container present within the
sterile field. The gauze is placed in this container if needed or moistened as desired for use. If
gauze is laying on the field and the field become moist, it may be considered contaminated.
The nurse assists a new nurse to add items to a sterile field. Which action by the new nurse
requires further instruction?
The nurse drops the item from the wrapper into the side of the sterile field.
The nurse keeps hands and wrists on the outside of the wrapped sterile item.
The nurse grasps the remaining flap of the wrapper and pulls back toward wrist.
The nurse holds wrapped item in dominant hand to open, opening top flap away from body. -
CORRECT ANSWER-The nurse drops the item from the wrapper into the side of the sterile field.
, Rationale: The outer edges of the sterile field are considered nonsterile. Dropping items into the
outer edges of the field causes those items to be considered contaminated. Items are dropped
toward the center of the field from approximately six inches above the surface of the field. The
nurse opens the package outward over the hands, maintaining the sterility of the item inside the
package. Items are typically held in the non-dominant hand while the dominant hand pulls the
package open.
Which should be documented by the nurse?
The specific items that the nurse transferred into a sterile field.
The fact that the nurse washed her hands before a procedure.
The fact that the nurse donned gloves two different times during a procedure.
The fact that sterile technique was used for a given procedure. - CORRECT ANSWER-The fact
that sterile technique was used for a given procedure.
Rationale: The fact that sterile technique was used for a given procedure should be documented,
but the other items listed do not need to be documented, as they are standard procedure.
The nurse prepares for a sterile procedure. What action does the nurse perform first?
Perform hand hygiene with alcohol-based handrub.
Place all the necessary supplies in the room.
Identify the client the procedure is prescribed for.
Put on personal protective equipment, if required. - CORRECT ANSWER-Perform hand hygiene
with alcohol-based handrub.
Rationale: Hand hygiene is done prior to donning any personal protective equipment, before
entering the room, and before interacting directly with the client, such as checking the name on the
armband.
The nurse needs to place gauze from a wrapped item into the sterile field. Which action does the
nurse take?
Remove the gauze from the package with one sterile hand.
Drop the item from 6 in (15 cm) above the sterile field.
Lay the item in an open package on the 1-in (2.5-cm) border.
Extend the sterile field by laying the open package beside it. - CORRECT ANSWER-Drop the item
from 6 in (15 cm) above the sterile field.
Rationale: Dropping the item from roughly 6 in (15 cm) above the surface prevents contamination
of the field or dropping the item too close to the 1-in (2.5-cm), nonsterile border. Removing the
gauze with one sterile hand risks contamination of that hand. It does not extend the sterile field to
lay an unsterile package to the outside of the 1-in (2.5-cm) border.
The nurse is preparing to administer a bolus of IV pain medication through a drug-infusion lock.
Before flushing the lock with saline, there is no blood return with aspiration. What would be the
initial recommended nursing intervention in this situation?
Check the patency of the tubing by injecting 3 mL sterile water.
Reassess the IV site for any infiltration or inflammation.
Forcefully attempt to flush the drug-infusion lock with saline, observing the site for changes.
Remove the device to another part of the arm. - CORRECT ANSWER-Reassess the IV site for
any infiltration or inflammation.
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