NR 326:
Taylor’s Clinical Nursing Skills Testbank 50 Questions With 100 %
Correct Answers and Rationale
1. When accessing the implanted port of a central venous access device (CVAD), what action
should the nurse take to ensure the port is patent?
A. Aspirate a few milliliters of blood into the extension tubing to check for blood
return.
B. Aspirate a few milliliters of blood into the syringe to check for blood return.
C. Open the clamp on the extension tubing and instill 3 to 5 mL of air.
D. 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.
2. 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?
A. Ask the client to perform a Valsalva maneuver and place the client's arm
below the heart.
B. Change the position of the client and lower the head of the bed.
C. Notify the health care provider immediately.
D. 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 needle should be removed and a new needle inserted. If the port does not
flush this time, the health care provider should be notified.
3. 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?
A. Right side of the port
B. Left side of the port
C. Top of the port
D. 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.
4. 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?
A. Flush the port with heparin.
B. Notify the health care provider.
C. Change the access needle.
D. 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.
5. 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?
A. Place the client's arm below the level of the heart and attempt to flush the
port.
B. Re-access the port with a new needle, according to facility policy.
C. Contact the health care provider for further prescription.
D. 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.
6. 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?
A. Auscultation
B. Observation
, C. Percussion
D. 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.
7. After accessing the implanted port of a client's central venous access device (CVAD), what
action does the nurse take to prevent air embolism?
A. Clamp the extension tubing
B. Start the intravenous infusion
C. Flush the extension tubing with normal saline
D. 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 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.
8. 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?
A. Place a mask on the client.
B. Urge the client not to cough.
C. Ask the client to hold the breath.
D. 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.
9. 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?
A. Obtain a new access needle and report the flawed needle to the facility's risk
manager.
B. Insert the needle through the skin into the center of the infusion port and begin the
infusion.
C. 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.
Taylor’s Clinical Nursing Skills Testbank 50 Questions With 100 %
Correct Answers and Rationale
1. When accessing the implanted port of a central venous access device (CVAD), what action
should the nurse take to ensure the port is patent?
A. Aspirate a few milliliters of blood into the extension tubing to check for blood
return.
B. Aspirate a few milliliters of blood into the syringe to check for blood return.
C. Open the clamp on the extension tubing and instill 3 to 5 mL of air.
D. 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.
2. 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?
A. Ask the client to perform a Valsalva maneuver and place the client's arm
below the heart.
B. Change the position of the client and lower the head of the bed.
C. Notify the health care provider immediately.
D. 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 needle should be removed and a new needle inserted. If the port does not
flush this time, the health care provider should be notified.
3. 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?
A. Right side of the port
B. Left side of the port
C. Top of the port
D. 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.
4. 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?
A. Flush the port with heparin.
B. Notify the health care provider.
C. Change the access needle.
D. 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.
5. 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?
A. Place the client's arm below the level of the heart and attempt to flush the
port.
B. Re-access the port with a new needle, according to facility policy.
C. Contact the health care provider for further prescription.
D. 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.
6. 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?
A. Auscultation
B. Observation
, C. Percussion
D. 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.
7. After accessing the implanted port of a client's central venous access device (CVAD), what
action does the nurse take to prevent air embolism?
A. Clamp the extension tubing
B. Start the intravenous infusion
C. Flush the extension tubing with normal saline
D. 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 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.
8. 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?
A. Place a mask on the client.
B. Urge the client not to cough.
C. Ask the client to hold the breath.
D. 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.
9. 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?
A. Obtain a new access needle and report the flawed needle to the facility's risk
manager.
B. Insert the needle through the skin into the center of the infusion port and begin the
infusion.
C. 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.
