PCCN Nursing Interventions & Procedures

Question 1

A nurse is preparing to suction a patient’s endotracheal tube. What is the most appropriate action before suctioning?

Accepted Answer

Hyperoxygenate the patient

Answer

Turn off the ventilator

Answer

Instill normal saline into the airway

Answer

Increase suction pressure to maximum

Question 2

What is the correct sequence for donning personal protective equipment (PPE)?

Accepted Answer

Gown, mask, goggles, gloves

Answer

Gloves, gown, mask, goggles

Answer

Mask, gown, gloves, goggles

Answer

Gown, gloves, mask, goggles

Question 3

Which intervention is most effective in preventing ventilator-associated pneumonia (VAP)?

Accepted Answer

Elevating the head of bed to 30–45 degrees

Answer

Suctioning every hour

Answer

Keeping the patient NPO

Answer

Administering broad-spectrum antibiotics

Question 4

A patient has a central venous catheter. Which sign most suggests a catheter-related bloodstream infection?

Accepted Answer

Fever with no obvious source

Answer

Edema around the insertion site

Answer

Phlebitis and vein discoloration

Answer

Tachypnea and wheezing

Question 5

What is the priority nursing action after inserting a nasogastric (NG) tube for feeding?

Accepted Answer

Confirm placement with an abdominal X-ray

Answer

Start the feeding immediately

Answer

Ask the patient if they can feel the tube in their throat

Answer

Clamp the tube and reassess in 30 minutes

Question 6

A nurse is caring for a patient with a chest tube. Which finding should be reported immediately?

Accepted Answer

Constant bubbling in the water seal chamber

Answer

Gentle bubbling in the suction chamber

Answer

Intermittent tidaling in the water seal

Answer

Drainage of 50 mL serosanguinous fluid in 2 hours

Question 7

Which action is appropriate when administering IV potassium chloride?

Accepted Answer

Use a central line for concentrations above 10 mEq/hr

Answer

Administer via IV push for rapid replacement

Answer

Mix with dextrose 5% in water (D5W) only

Answer

Give with loop diuretics simultaneously

Question 8

A patient on telemetry suddenly reports chest pain and shortness of breath. What should the nurse do first?

Accepted Answer

Assess vital signs and cardiac monitor

Answer

Call respiratory therapy

Answer

Increase oxygen flow rate

Answer

Notify the physician

Question 9

Which of the following best reflects proper technique when inserting an indwelling urinary catheter in a female patient?

Accepted Answer

Use sterile gloves and sterile technique

Answer

Inflate the balloon before advancing the catheter

Answer

Insert catheter 1 inch beyond urine flow return

Answer

Use clean gloves and clean technique

A nurse is preparing to suction a patient’s endotracheal tube.What is the most appropriate action before suctioning?