Know the device before you answer the question
Central venous access devices differ in dwell time, insertion site and who may care for them, and the exam expects you to match the device to the situation. A non-tunnelled percutaneous catheter placed in the internal jugular or subclavian vein is a short-term device used for days in acute care. A peripherally inserted central catheter, or PICC, enters at the basilic or brachial vein and terminates in the superior vena cava, and it supports weeks to months of therapy including home infusions.
Tunnelled catheters such as Hickman or Broviac lines are surgically placed with a cuff that anchors the catheter and reduces infection risk, making them appropriate for long-term therapy. Implanted ports sit entirely under the skin and are accessed with a non-coring Huber needle, which is the detail the exam most often tests — using a standard needle damages the septum and is always the wrong answer.
Regardless of device, the indications are the same: vesicant or irritant medications such as chemotherapy, parenteral nutrition, prolonged antibiotic therapy, frequent blood sampling, haemodynamic monitoring and infusions with extremes of pH or osmolarity. When a stem asks why a peripheral line will not do, the answer usually names one of these.
| Device | Typical duration | Key nursing point |
|---|---|---|
| Non-tunnelled central catheter | Days to weeks | Highest infection risk; sterile dressing changes |
| PICC | Weeks to months | Measure arm circumference; no blood pressure in that arm |
| Tunnelled (Hickman, Broviac) | Months to years | Cuff anchors line; lower infection risk |
| Implanted port | Years | Access only with a non-coring Huber needle |
| Dialysis catheter | Weeks to months | Not used for routine infusions or draws |
Insertion, verification and daily maintenance
During insertion the client is placed in Trendelenburg for subclavian or internal jugular placement to distend the vein and reduce air entry risk, and is asked to turn the head away from the site. Maximal sterile barrier precautions apply: cap, mask, sterile gown, sterile gloves and a full-body drape. The nurse's role includes confirming consent, positioning, monitoring vital signs and oxygen saturation, and having the client perform the Valsalva manoeuvre when the catheter hub is open.
After insertion, a chest x-ray verifies tip location in the lower superior vena cava and rules out pneumothorax. No infusion begins until placement is confirmed and documented. Sudden dyspnoea, decreased breath sounds on one side or chest pain after insertion suggests pneumothorax and is reported immediately.
Daily maintenance is the highest-yield content. Assess the site each shift for redness, tenderness, swelling and drainage. Scrub the needleless connector with alcohol or chlorhexidine for fifteen seconds and let it dry before each access. Flush with normal saline using a pulsatile push and finish with positive pressure clamping to prevent reflux. Never use a syringe smaller than ten millilitres because the smaller barrel generates pressure high enough to rupture the catheter. Change administration sets every ninety-six hours, and every twenty-four hours for lipids or blood.
- •Confirm tip placement by x-ray before first use
- •Transparent dressing every 7 days, gauze every 2 days, sooner if compromised
- •Chlorhexidine skin antisepsis with a 30-second scrub and full air-dry
- •10 mL or larger syringes only
- •Client wears a mask and turns away during dressing changes
- •Remove any line as soon as it is no longer clinically needed
Complications and the priority action for each
Air embolism is the emergency the exam loves. It presents abruptly during tubing changes, cap disconnection or removal with sudden dyspnoea, chest pain, hypotension, tachycardia, anxiety and sometimes a churning murmur. The immediate action sequence is to clamp the catheter, position the client on the left side with the head lower than the feet so air is trapped in the right ventricle, administer high-flow oxygen and notify the provider. To prevent it, clamp before disconnecting and have the client hold their breath and bear down during hub-open moments.
Catheter-related bloodstream infection presents with fever, chills, and site erythema or purulence, sometimes with rigors immediately after flushing. Blood cultures are drawn from both the line and a peripheral site before antibiotics start. Occlusion presents as sluggish flow or inability to aspirate; the nurse checks for kinks and closed clamps, repositions the client and has them raise their arm or cough before considering a thrombolytic instillation with a provider order — force is never applied to a resistant line.
Other tested complications include catheter migration, indicated by a change in external catheter length or arm swelling; pinch-off syndrome with positional flow in subclavian lines; and thrombosis, suggested by unilateral arm, neck or facial swelling with a PICC. Each answer follows the same logic: stop infusing, assess, and report.
| Complication | Presentation | First action |
|---|---|---|
| Air embolism | Sudden dyspnoea, chest pain, hypotension | Clamp line, left lateral Trendelenburg, oxygen |
| Pneumothorax | Dyspnoea, absent breath sounds after insertion | Oxygen, assess, notify provider, prepare chest x-ray |
| CLABSI | Fever, chills, purulent site | Cultures from line and periphery, notify provider |
| Occlusion | Cannot flush or aspirate | Check clamps and kinks, reposition; never force |
| Thrombosis | Unilateral arm or neck swelling | Stop infusion, elevate, notify provider |
Removal, documentation and client teaching
Removal is an air-embolism risk point. Place the client supine or in Trendelenburg, ask them to take a breath and bear down as the catheter is withdrawn, apply firm pressure for at least one minute, and cover the site with an occlusive petroleum-based dressing that stays on for twenty-four hours. Inspect the removed catheter and document that it is intact, along with tip length, site appearance and client tolerance.
Documentation on the exam means recording device type, external catheter length, site assessment, dressing change date, flush volumes and any client education given. A change in external length between shifts is a reportable finding, not a charting footnote.
Home teaching focuses on protecting the line and recognizing trouble early. Clients keep the dressing clean and dry, shower with a waterproof cover rather than submerging, avoid heavy lifting or blood pressure measurement on the PICC arm, carry clamps for emergencies, and call immediately for fever, chills, site drainage, swelling, catheter damage or a line that will not flush. Reinforcing hand hygiene before every contact remains the single most effective infection prevention step.