Documentation Flashcards
7 cards from real VABC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Documentation flashcards as text
When documenting a PICC insertion, which anatomical landmark must be recorded to confirm tip position?
Answer: Cavoatrial junction or lower third of superior vena cava
PICC tip position must be documented as residing at the cavoatrial junction or the lower third of the SVC for safe central venous infusion.
Which element is REQUIRED when documenting a failed venipuncture attempt?
Answer: Site attempted, gauge used, and reason for failure
Documentation of a failed attempt must include the anatomical site, catheter gauge, and the reason the attempt was unsuccessful.
How should an infusion nurse document verbal consent for a peripheral IV insertion when a written consent form is not required?
Answer: Note in the medical record that verbal consent was obtained
Verbal consent should be noted in the medical record to demonstrate that the patient was informed and agreed to the procedure.
When documenting catheter flushing, which information is MOST essential to include?
Answer: Type and volume of flush solution and patient response
Documentation of flushing must capture the flush solution type (e.g., normal saline), volume used, and the patient's response to ensure accountability.
A patient's central venous catheter dressing is changed. Which detail is LEAST necessary in the dressing change documentation?
Answer: Color of the patient's hospital gown
The patient's gown color has no clinical relevance; site condition, dressing type, and timing are all required elements.
What does documenting 'blood return confirmed' prior to infusion demonstrate?
Answer: That patency and correct catheter placement were verified
Documenting blood return confirms catheter patency and suggests proper intravascular placement before initiating infusion.
Under HIPAA, vascular access documentation shared with another care team member must be:
Answer: Shared only through secure, authorized channels for treatment purposes
HIPAA requires that protected health information, including vascular access records, be shared only through secure, authorized systems for legitimate treatment purposes.