NCLEX Fundamentals: Skills/Procedures
The nurse is caring for a client who is having a thoracentesis. Following the procedure, the nurse monitors for complications. The initial postprocedure monitoring plan should include what?
- Level of alertness - O2 sat - Lung sounds - Respiratory pattern - Temperature is NOT included in this because s/s of infection do not occur until days later
The nurse is suctioning the artificial airway of a conscious client. Which actions demonstrate correct technique?
1) Apply suction for no longer than 5-10 seconds 2) Wait at least 1 minute between suction passes
Ten minutes after an infusion of packed red blood cells (PRBCs) is initiated through a central venous catheter (CVC), the client has shortness of breath and slight chest tightness. What initial actions would be appropriate for the nurse to complete?
1) Assess the patient's breath sounds 2) Notify HCP 3) Stop the infusion
The nurse prepares to administer a cleansing enema to a client with constipation. Which interventions are appropriate?
1) Assist patient into LL position with right knee flexed 2) Encourage patient to retain enema for as long as possible 3) Insert tubing into rectum with tip directed towards the umbilicus 4) Slow administration rate if cramping
The nurse is reinforcing education about ascending stairs using a modified 3-point gait to a client prescribed crutches after a left ankle sprain. Place the instructions for ascending the stairs in the correct order.
1) Assume the tripod position, then bear body weight on the crutches 2) Place the unaffected leg onto the stair 3) Advance the affected leg and crutches up the stair 4) Transfer body weight to the unaffected leg and raise the body onto the stair
Which procedures are appropriate for the nurse to use when obtaining an adult client's blood for a laboratory test?
1) Avoid the arm on the affected side after a mastectomy 2) Do not make further attempts to draw blood after 2 missed times 3) Insert the needle bevel up at a 15 degree angle
The nurse is performing a central line tubing change when the client suddenly begins gasping for air and writhing. Order the interventions by priority.
1) Clamp the catheter tubing 2) Place the client in Trendelenburg position on the left side 3) Administer oxygen as needed 4) Notify the health care provider (HCP) 5) Stay with the client and provide reassurance
The nurse prepares to draw up regular and NPH insulins into one syringe. Place in order the steps the nurse should take when mixing the insulins.
1) Clean the vial tops with alcohol swabs 2) Inject air into the NPH insulin vial 3) Inject air into the regular insulin vial 4) Draw up the regular insulin solution 5) Draw up the NPH insulin solution
The nurse is preparing to administer several medications through a client's feeding tube. None of the medications are extended release. Which of the following actions should the nurse implement?
1) Crush each med individually before giving 2) Determine if medication are available in liquid form 3) Flush tube before and after
The nurse is drawing blood from a client's peripheral vein for laboratory specimens. Which of the following are correct nursing actions?
1) Do not leave the tourniquet on for more than 1 minute while looking for a vein 2) If pulsating red blood is noted, withdraw needle and apply pressure for 5 mins
The nurse initiates a norepinephrine infusion through a client's only IV access into a large peripheral vein. The client reports severe pain at the IV site shortly after the infusion is started, and blanching is visible along the vein pathway. Which nursing interventions are appropriate?
1) Elevate the affected extremity above the level of the heart 2) Notify HCP and prepare phentolamine 3) Stop the infusion immediately and disconnect the tubing - Norepinephrine (Levophed) is a vasoconstrictor and vesicant that can cause skin breakdown and/or necrosis if absorbed into the tissue. Pain, blanching, swelling, and redness are signs of extravasation. Norepinephrine should be infused through a central line when possible.
A client with a nasogastric tube is prescribed intermittent bolus enteral feedings with routine gastric residual checks. Which of the following actions by the nurse are appropriate?
1) Flush the NG tube before and after the feeding 2) Place the patient in semi fowlers 3) Start the feeding after obtaining gastric residual volume of 75 mL
Which interventions should the nurse perform when assisting the health care provider with removal of a client's chest tube?
1) Give patient pain med 30-60 min prior 2) Tell patient to breathe in, hold it, and bear down when removing the tube 3) Prepare sterile airtight petroleum jelly gauze dressing 4) Provide HCP with sterile suture removal equipment
The nurse prepares to insert a large-bore nasogastric tube for gastric decompression. After obtaining equipment, the nurse identifies the client, performs hand hygiene, applies clean gloves, assesses nares, and selects a naris. Place the remaining steps in the correct order.
1) Instruct client to extend neck back slightly 2) Gently insert tube just past nasopharynx 3) Ask client to flex head forward and swallow 4) Advance tube to the marked point 5) Verify tube placement and anchor Measure, mark, and lubricate tube
The primary health care provider prescribes a 24-hour urine collection for a client with suspected Cushing syndrome. Which instructions should the nurse give the client regarding this test?
1) Keep the urine collection container on ice or in fridge when not in use 2) Record the time the urine collection is started and then empty bladder into the toilet so that the start time coincides with an empty bladder 3) You will be given a dark plastic jug containing a powder that absorbs into the urine that will collect in the jug - The urine is tested for free cortisol, and results >80-120 mcg/24 hr (220-330 nmol/day) indicate that Cushing syndrome is present.
The nurse prepares equipment for insertion of a large-bore nasogastric (NG) tube for a hospitalized client. Which actions should the nurse take to measure and mark the tube?
1) Measure from tip of the nose to earlobe, to xyphoid process 2) Place a small piece of tape at the point of measurement
The nurse is preparing a client for a magnetic resonance cholangiopancreatography. Which statements by the client would require the nurse to obtain further assessment data?
1) My last period was 6 weeks ago 2) I have a hearing aid implanted in my ear 3) I had a rash the last time I had IV contrast - Many clients should be NPO for 4 hours prior to the procedure to allow better visualization of the anatomical features. - Smoking does not affect MRI visualization and is not a contraindication.
The nurse is preparing to suction secretions from the airway of an unconscious client whose lungs are mechanically ventilated with an endotracheal tube. Place the steps for suctioning the endotracheal tube in the correct order.
1) Perform hand hygiene and don clean gloves. 2) Suction the oropharynx and perform oral care. 3) Hyper-oxygenate lungs at 100% O2 4) Advance catheter into trachea 5) Gently rotate catheter while suctioning 6) Evaluate patient tolerance and document
The nurse is changing the dressing, injection caps, and IV tubing of a client who is receiving total parenteral nutrition through a right peripherally inserted central venous catheter. The nurse should implement what actions to prevent complications during this procedure?
1) Tell patient to hold their breath when changing injection caps 2) wash hands before and after 3) Wear sterile gloves and surgical mask when changing the dressing (see more in google docs)
The nurse working in an intensive care unit receives a prescription from the primary health care provider to discontinue a triple-lumen subclavian central venous catheter. Which interventions will help prevent air embolism on removal?
1) use air occlusive dressing 2) bear down or exhale while RN removes line 3) instruct patient to lie supine
The nurse is preparing to flush a client's central venous catheter. Which size syringe is best for the nurse to choose?
10 mL
How long should the nurse limit each suction pass?
< 10 seconds
What are central venous catheters used for?
A central venous catheter is used to administer fluids, for simultaneous infusion of incompatible drugs, for parenteral nutrition, and for hemodynamic monitoring.
How are hearing aids cleaned?
Clean hearing aids with a soft cloth
what should gastric pH be?
Gastric pH should be less than 5
How is net fluid balance calculated?
Add all input in mL and subtract the output
The nurse is performing open endotracheal suctioning for a client with a tracheostomy tube. Which of the following actions by the nurse are appropriate?
Administers 100% O2 prior to suctioning Applies suction while withdrawing the catheter from the airway Uses sterile gloves and technique throughout the procedure
The nurse is administering cleansing enemas to a client the night before bowel surgery. During instillation of the enema, the client reports cramping and pain. What action should the nurse take?
Assess for rising pulse and respirations afterward Check PT/INR and PTT before procedure Ensure patient's blood is cross typed and matched - during biopsy lie supine with right arm over the head while holding breath - lie on right side post biopsy
An elderly client is brought to the emergency department with lethargy, chills, and sharp chest pain with deep breathing. Pulse oximeter shows 93% on room air and respirations are 24/min. What is the nurse's initial action?
Auscultate lung sounds - I chose give O2, but assessment is done first according to uworld
A nurse prepares to administer an intermittent enteral feeding via nasogastric tube to a client with a prescription for gastric residual checks before each feeding. The nurse obtains a gastric residual volume of 80 mL. Which action should the nurse perform next?
Collect gastric pH measurement
What maneuver is used to save infant under 1 choking?
Back blows and chest thrusts
A 55-year-old male client has a 16-Fr indwelling urethral catheter with a 5-mL balloon inserted to relieve postoperative urinary retention. The nurse observes urine leaking from the insertion site, past the catheter. What is the nurse's first action?
Check the urethral catheter and drainage tubing
The nurse is assigned to care for a hospitalized confused client with an indwelling urinary catheter. On entering the client's room, the nurse notes the client pulling at the catheter and grimacing in pain. Blood is trickling from the client's meatus and the urine in the drainage bag is pink. Which action should the nurse take first?
Deflate the balloon of the catheter
The nurse is inserting an indwelling (Foley) urinary catheter into a male client. After inserting the catheter about 6 in (15.2 cm), the nurse notes drops of urine in the tubing. What action should the nurse take next?
Further insert catheter 1-2 inches - it is recommended that the catheter be inserted 7-9 in
The charge nurse observes a new staff nurse collecting a urine sample for urinalysis and culture as pictured. What is the charge nurse's best action? (in pic they are taking sample from catheter collection bag)
Discard of the sample and record the output - A urine specimen is collected aseptically from the specimen port in an indwelling urinary catheter. - Urine that has been collected from the collection bag does not yield accurate urinalysis and culture results.
A client started a 24-hour urine collection test at 6:00 AM. The unlicensed assistive personnel (UAP) reports discarding a urine specimen of 250 mL at 10:00 AM by mistake but adding all specimens to the collection container before and after that time. What action should the nurse take?
Discard urine a container, and restart the 24 hour urine collection tomorrow morning
The nurse performs tracheostomy care for a client with a disposable inner cannula and tracheostomy dressing. Place the steps in the correct order.
Gather supplies and position client 2. Don mask, goggles, and clean gloves 5. Remove soiled dressing 3. Don sterile gloves; remove old disposable cannula and replace with a new one 1. Clean around stoma with sterile water or saline; dry and replace sterile gauze pad
The nurse inserts a urinary catheter into a female client who has not voided for 6 hours. No urine is returned. What action should the nurse take next?
Leave the catheter in place and insert a new catheter higher up in the perineal area since the first one may have gone into the vagina
The nurse notes muffled heart tones in a client with a pericardial effusion. How would the nurse assess for a pulsus paradoxus?
Measure the difference between Korotoff sounds auscultated during expiration and throughout the respiratory cycle
The nurse plans to start an IV line on a female client hospitalized with pneumonia. The nurse reviews the electronic medical record for relevant information and learns that the client is right-handed and has a history of a left-sided mastectomy with lymph node removal. Which site is best for the nurse to select for the client's IV line?
Median vein of the right forearm
A nurse is caring for a 2-year-old child diagnosed with nephrotic syndrome who is in diapers and has red, edematous genitals. Which collection technique is appropriate for the nurse to obtain daily urine specimens for proteinuria testing with a urine dipstick?
Place cotton balls into a dry diaper and squeeze urine onto a dipstick - Children with nephrotic syndrome have a high risk for infection from immunosuppressive effects of corticosteroid therapy. Intermittent or continuous catheterizations are invasive procedures that may cause urinary tract infections.
The 70-year-old client with type 2 diabetes and hypertension is scheduled for ureteral stent removal in 2 hours. The preoperative protocol ECG is done in the inpatient unit, and results indicate a "possibly acute" ST segment elevation. What action is most important for the nurse to take?
Report to the HCP about the test results
The nurse attempts to flush a client's subclavian vein central venous access device with normal saline using a 10-mL syringe, but meets resistance, is unable to aspirate blood, and suspects an occlusion. What should the nurse do next?
Reposition the patient - The nurse should first attempt to remove the occlusion by eliminating a possible mechanical obstruction (eg, reposition client to adjust catheter tip location) before notifying the health care provider. - do this before notifying HCP
The student nurse is applying a condom catheter for an ambulatory client who is uncircumcised and incontinent of urine. The precepting nurse should intervene when the student performs which action?
Retracts the foreskin before applying condom sheath - Health care providers should ensure a client's foreskin is fully reduced before applying a condom catheter, as prolonged retraction can cause paraphimosis, progressive swelling of the foreskin, vascular compromise, and permanent damage to the glans. - A 1-2 in (2.5-5 cm) space should be left between the tip of the penis and the end of the condom to prevent penile irritation and pooling of urine in the condom.
The nurse is reinforcing instructions to a client on collection of a sputum specimen for culture and sensitivity. Which of the following client statements indicate that teaching has been effective?
Rinse the mouth with water before collecting the sputum sample to reduce bacteria in the mouth and prevent specimen contamination by oral flora (Option 1) Avoid touching the inside of the sterile container or lid to avoid accidental specimen contamination by normal flora of the skin (Option 2) Inhale deeply several times and then cough forcefully, which promotes expectoration of lower lung secretions and increases sample volume (Option 3) Assume a sitting or upright position before specimen collection, if possible, to promote cough strength during collection Collect specimen early in the morning upon waking
The nurse is administering cleansing enemas to a client the night before bowel surgery. During instillation of the enema, the client reports cramping and pain. What action should the nurse take?
Stop infusing for 30 seconds and resume at a slower rate
Suction control chamber facts
This is the suction control chamber, which is usually set at -20 cm H2O to maintain negative pressure in the system. Bubbling will occur when suction is applied.
What pressure should suction be set at when suctioning a trach?
Suction should be set at medium pressure (100-120 mm Hg for adults, 50-75 mm Hg for children)
Air leak gauge facts
The air leak gauge (part of the water seal chamber) allows for assessment of air leaks. Continuous bubbling indicates an air leak in the system.
How should a patient be positioned after a pneumonectomy?
The client should be positioned on the surgical side to promote adequate expansion and ventilation of the remaining lung.
A client with a dislocated shoulder is prescribed a shoulder sling. The nurse applies the sling and evaluates the fit before discharge from the emergency room. Which assessment finding indicates an incorrect fit?
The hand is held sightly below elbow level
What rate should IV K+ not exceed?
The infusion rate should not exceed 10 mEq/hr (10 mmol/hr). Therefore, IVPB KCL must be given via an infusion pump so the rate can be regulated. IV KCL should be diluted and never given in a concentrated amount.
The nurse is caring for a client with newly prescribed hearing aids. Which of the following actions by the client indicate proper use and care of hearing aids?
Turns TV down when talking to the nurse Lowers TV volume completely down when inserting the aid into the ear Verifies that the battery compartment is closed before insertion Remove battery at night when not in use to extend battery life
The nurse helps the health care provider perform a thoracentesis at the bedside. In which position does the nurse place the client to facilitate needle insertion and promote comfort?
Upright leaning forward over the bedside table, with arms supported on pillows
A nurse is caring for a client who has a chest tube drainage system in place. Where would the nurse observe to assess for tidaling?
Water seal chamber - The water level in the water seal chamber rises and falls with inspiration and expiration, a process known as tidaling which means the connection is working properly.
The nurse is drawing a blood specimen from the client's right basilic vein. The client cries out, retracts the arm, and reports feeling "pins and needles" in the right arm. Which action by the nurse is appropriate?
Withdraw the needle and reattempt in a different site with new equipment
Where is the apical pulse located?
in the 5th intercostal space
How big should the syringe be for newborn injections?
needle length should be ⅝ inch for newborns and ⅝ to 1 inch for infants; these lengths are adequate for reaching the muscle mass while avoiding underlying tissues (eg, nerves, bone). A 22- to 25-gauge needle is appropriate for clients age <12 months. - 1mL syringe
How should blood be drawn if necessary to draw from an arm with an IV infusing?
the specimen should be collected from a vein several centimeters below (distal to) the point of IV infusion, with the tourniquet placed in between. - NEVER draw blood above an infusing IV site