Taylor-s Clinical Nursing Skills Test Bank Questions and Answers

Taylor's Clinical Nursing Skills Tast Bank Questions and 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 millilitres of blood into the extension tubing to check for blood return. Aspirate a few millilitres 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. Aspirate a few millilitres 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 millilitres 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. 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 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 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.