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

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)?

Accepted Answer

Gown, mask, goggles, gloves

Answer

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)?

Accepted Answer

Elevating the head of bed to 30–45 degrees

Answer

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?

Accepted Answer

Fever with no obvious source

Answer

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?

Accepted Answer

Confirm placement with an abdominal X-ray

Answer

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.

PCCN Exam Practice Test

PCCN Exam Practice Test

PCCN Nursing Interventions & Procedures