Next Clinical Skills and Procedures Flashcards

Which assessment finding is a priority concern in a patient receiving a blood transfusion 15 minutes into the infusion?

Answer: Temperature rise of 1.8°F (1°C) with chills and back pain

A temperature rise with chills and back pain during transfusion are classic signs of an acute hemolytic transfusion reaction, which is life-threatening and requires stopping the transfusion immediately.

When collecting a clean-catch midstream urine specimen from a female patient, the correct cleansing direction is:

Answer: Front to back, one wipe per swab

Cleansing front to back with a single wipe per swab prevents contamination of the urethral meatus with perianal bacteria.

A nurse is performing range-of-motion (ROM) exercises on a patient's shoulder. Which action is correct?

Answer: Support the joint proximally and distally while moving it through its full comfortable range

Proper ROM technique requires supporting the joint above and below while moving it through its comfortable range to prevent injury and provide stability.

Which finding would indicate that chest percussion and postural drainage have been effective for a patient with pneumonia?

Answer: Productive cough with mobilization of secretions

A productive cough that brings up secretions indicates the airway clearance techniques have successfully mobilized and expelled mucus from the airways.

When providing colostomy care, which observation should the nurse report to the healthcare provider?

Answer: Stoma appears dark purple or black

A dark purple or black stoma indicates ischemia or necrosis of the intestinal tissue and is an emergency requiring immediate medical evaluation.

A patient is being prepared for a lumbar puncture. Which position should the nurse assist the patient into?

Answer: Lateral recumbent with knees drawn to chest (fetal position)

The fetal (lateral recumbent) position maximally flexes the spine, widens the intervertebral spaces, and allows safe needle insertion into the subarachnoid space.