PCCN Nursing Interventions & Procedures — Questions and Answers
Question 1: A nurse is preparing to suction a patient’s endotracheal tube. What is the most appropriate action before suctioning?
- Turn off the ventilator
- Instill normal saline into the airway
- Hyperoxygenate the patient (Correct answer)
- Increase suction pressure to maximum
Correct answer: Hyperoxygenate the patient
Hyperoxygenating the patient before suctioning is a crucial step to prevent hypoxemia, which can occur during the procedure due to the removal of oxygen from the airway. This action helps to maintain adequate oxygen saturation and minimize the risk of complications such as arrhythmias or cardiac arrest. It ensures the patient has a reserve of oxygen during the temporary interruption of ventilation.
Question 2: What is the correct sequence for donning personal protective equipment (PPE)?
- Gown, mask, goggles, gloves (Correct answer)
- Gloves, gown, mask, goggles
- Mask, gown, gloves, goggles
- Gown, gloves, mask, goggles
Correct answer: Gown, mask, goggles, gloves
The correct sequence for donning personal protective equipment (PPE) is designed to protect the healthcare worker from contamination, starting with the body and moving to the hands. Donning the gown first covers the body, followed by the mask and goggles for facial protection, and finally gloves as the last barrier for direct contact. This order ensures maximum protection and minimizes self-contamination.
Question 3: Which intervention is most effective in preventing ventilator-associated pneumonia (VAP)?
- Suctioning every hour
- Elevating the head of bed to 30–45 degrees (Correct answer)
- Keeping the patient NPO
- Administering broad-spectrum antibiotics
Correct answer: Elevating the head of bed to 30–45 degrees
Elevating the head of the bed to 30-45 degrees (semi-recumbent position) is a cornerstone intervention for preventing ventilator-associated pneumonia (VAP). This position helps to reduce gastric reflux and the aspiration of oral and gastric secretions into the lungs, which are primary pathways for bacterial entry and subsequent pneumonia development in mechanically ventilated patients.
Question 4: A patient has a central venous catheter. Which sign most suggests a catheter-related bloodstream infection?
- Edema around the insertion site
- Phlebitis and vein discoloration
- Fever with no obvious source (Correct answer)
- Tachypnea and wheezing
Correct answer: Fever with no obvious source
Fever with no obvious source is a hallmark sign of a catheter-related bloodstream infection (CRBSI). While local signs like redness or edema can occur, a systemic fever without another identifiable cause strongly suggests that the central line is the source of infection. Prompt investigation and management are crucial to prevent severe sepsis.
Question 5: What is the priority nursing action after inserting a nasogastric (NG) tube for feeding?
- Start the feeding immediately
- Ask the patient if they can feel the tube in their throat
- Confirm placement with an abdominal X-ray (Correct answer)
- Clamp the tube and reassess in 30 minutes
Correct answer: Confirm placement with an abdominal X-ray
Confirming nasogastric (NG) tube placement with an abdominal X-ray is the most reliable and gold standard method to ensure the tube is correctly positioned in the stomach or small intestine. This critical step prevents serious complications such as aspiration pneumonia if the tube were inadvertently placed in the lungs. Never initiate feeding until placement is radiographically confirmed.
Question 6: A nurse is caring for a patient with a chest tube. Which finding should be reported immediately?
- Gentle bubbling in the suction chamber
- Intermittent tidaling in the water seal
- Constant bubbling in the water seal chamber (Correct answer)
- Drainage of 50 mL serosanguinous fluid in 2 hours
Correct answer: Constant bubbling in the water seal chamber
Constant bubbling in the water seal chamber, especially if it's a new finding or persists after an initial air leak has resolved, indicates a persistent air leak in the chest tube system or from the patient's lung. This requires immediate investigation and intervention as it suggests ongoing air leakage from the pleural space or a problem with the tubing integrity. Gentle bubbling in the suction chamber is normal.
Question 7: Which action is appropriate when administering IV potassium chloride?
- Administer via IV push for rapid replacement
- Use a central line for concentrations above 10 mEq/hr (Correct answer)
- Mix with dextrose 5% in water (D5W) only
- Give with loop diuretics simultaneously
Correct answer: Use a central line for concentrations above 10 mEq/hr
Intravenous potassium chloride is a high-alert medication that can cause severe irritation and damage to peripheral veins, especially at higher concentrations or rapid infusion rates. Therefore, concentrations exceeding 10 mEq/hr are typically administered via a central venous catheter. This allows for greater dilution and minimizes the risk of phlebitis, pain, and tissue damage.
Question 8: A patient on telemetry suddenly reports chest pain and shortness of breath. What should the nurse do first?
- Call respiratory therapy
- Increase oxygen flow rate
- Notify the physician
- Assess vital signs and cardiac monitor (Correct answer)
Correct answer: Assess vital signs and cardiac monitor
When a patient on telemetry reports acute symptoms like chest pain and shortness of breath, the priority is to immediately assess their physiological status. This involves checking vital signs and observing the cardiac monitor for any changes, which provides critical information to guide subsequent interventions. This rapid assessment allows the nurse to determine the severity of the situation and initiate appropriate care.
Question 9: Which of the following best reflects proper technique when inserting an indwelling urinary catheter in a female patient?
- Inflate the balloon before advancing the catheter
- Insert catheter 1 inch beyond urine flow return
- Use sterile gloves and sterile technique (Correct answer)
- Use clean gloves and clean technique
Correct answer: Use sterile gloves and sterile technique
Inserting an indwelling urinary catheter is a sterile procedure that requires the use of sterile gloves and strict sterile technique. This is crucial to prevent the introduction of microorganisms into the urinary tract, thereby minimizing the risk of catheter-associated urinary tract infections (CAUTIs). Maintaining sterility throughout the procedure is paramount for patient safety.
PCCN Nursing Interventions & Procedures
A nurse is preparing to suction a patient’s endotracheal tube.
What is the most appropriate action before suctioning?