FUNDAMENTALS – intake.

The nurse should record all

SKILLS/PROCEDURES occurrences of intake and output.
• Daily weights are always the best indicator
CALCULATIONS of fluid balance; however, calculating net
CASE: The nurse is caring for a client with fluid balance from intake and output helps
gastroenteritis and dehydration who is to identify clients at risk for a fluid volume
prescribed strict intake and output monitoring imbalance. The following steps are used to
with calculation of net fluid balance each calculate the net fluid balance:
shift. Calculate the client's net fluid balance 1. Convert all volumes to milliliters
for the shift.
• (1 L )(1000 mLL )=1000 mL normal
ANS: 655 saline1 L 1000 mLL =1000 mL normal
saline
• (5 tbsp )(15 mLtbsp)=75 mL vanco
mycin5 tbsp 15 mLtbsp=75 mL vancom
ycin
2. Calculate intake and output totals
• Intake: 180 mL+75 mL+240 mL+36
0 mL+1000 mL+250 mL=2105 mL t
otal
intakeIntake: 180 mL+75 mL+240 mL+3
60 mL+1000 mL+250 mL=2105 mL total
intake
• Output: 150 mL+1300 mL=1450 mL
total
outputOutput: 150 mL+1300 mL=1450
mL total output
3. Calculate the net fluid balance
• Total intake−total output=net fluid
balanceTotal intake-total output=net
fluid balance
• 2105 mL−1450 mL=655 mL2105 mL
-1450 mL=655 mL

CASE: The health care provider prescribes a

continuous IV infusion of regular insulin at 5
units/hr. The infusion bag contains 50 units
of regular insulin in 100 mL of normal saline
solution. At what rate in milliliters per hour
(mL/hr) does the nurse set the IV pump?

ANS: 10

• Net fluid balance is calculated

by subtracting total output from total
 infuse at 10 mEq/hr. The pharmacy sends
20 mEq of KCl in 250 mL of D5W. To deliver
the prescribed dose, the nurse sets the
infusion pump at how many milliliters per
hour (mL/hr)?

ANS: 125ML/HR

CASE: The nurse has received a prescription

from the health care provider to administer
80 mg of methylprednisolone IV
piggyback. The available vial contains 125
mg in 2 mL. Select the syringe containing
the appropriate amount of medication to be CASE: The nurse cares for an 11-lb (5-kg)
administered. infant admitted with dehydration and
prepares to calculate intake and output over
an 8-hour shift. Using the data in the exhibit,
calculate the total output in milliliters for the
8-hour shift.

ANS: 178ML

CASE: A client with heart failure is

prescribed a continuous IV infusion of
dobutamine at 10 mcg/kg/min. He weighs 70
kg. The concentration of dobutamine is 250
mg in 500 mL D5W. For how many milliliters
per hour should the nurse program the IV
pump?

ANS: 84

• Dobutamine hydrochloride (Dobutrex) is a

positive inotropic drug that increases
cardiac muscle contractility. The dosage is
CASE: A client with hypokalemia is weight-based and is prescribed in
prescribed IV potassium chloride (KCl) to micrograms per kilogram per minute
 (mcg/kg/min) and administered with an IV
pump. Because IV pumps are set by CASE: The health care provider prescribes a
milliliters per hour (mL/hr), the nurse must continuous heparin infusion at 18 units/kg/hr
be able to calculate the drug dose and the for a client who has a pulmonary embolus
infusion rate in mL/hr. and weighs 198 lb. The infusion bag
• Dobutrex can be diluted in dextrose or contains 25,000 units of heparin in 500 mL of
normal saline, and concentrations usually D5W. At what rate in milliliters per hour
range from 500-2,000 micrograms per (mL/hr) does the nurse set the IV infusion
milliliter (mcg/mL) depending on client pump?
status. This medication may be
administered in acute or long-term facilities ANS: 32
or in the home. It is most often
administered in the emergency department,
intensive care unit, and step-down
units. The nurse must always follow
institution policy and procedure in relation
to its dilution, dosage, administration, and
titration.

CASE: The nurse is caring for a client who is

prescribed ampicillin 1.5 g in 100 mL of
normal saline IV to be administered over 30
minutes every 6 hours. The nurse has IV
tubing with a drip factor of 15 gtt/mL. At
what rate in drips per minute (gtt/min) should
CASE: The nurse is to administer an the nurse administer the IV ampicillin?
albuterol nebulizer treatment to a client with
acute bronchospasm. The prescribed ANS: 50
dosage is 5 mg every 4 hours. The available
solution is albuterol (0.083%) inhaled, 2.5
mg/3 mL. How many milliliters (mL) should
the nurse administer with each dose?

ANS: 6
CASE: The nurse is to administer prescribed lb. Based on the available concentration of
heparin 70 units/kg IV bolus before initiating cefuroxime, how many mL would the nurse
the continuous infusion as administer per dose?
prescribed. Heparin 1,000 units/mL is
available. The client weighs 108 lb. How ANS: 4.6
many milliliters of heparin bolus should the
nurse administer?

ANS: 3.4

CASE: A client postoperative from a

transurethral prostatectomy has a triple-
lumen, indwelling urinary catheter and is
receiving continuous bladder irrigation of
sterile normal saline solution at 175
mL/hr. The nurse empties the urine drainage
CASE: A continuous regular insulin IV bag for a total of 2300 mL at the end of the
infusion of 0.2 units/kg/hr is prescribed for a 8-hour shift. How many milliliters (mL)
10-year-old client who weighs 51 lb and has should the nurse document as the net urine
diabetes mellitus. How many units per hour output for the shift?
(units/hr) would the nurse administer to this
client? ANS: 900

ANS: 4.6

CASE: The health care provider prescribes 2

mEq (2 mmol)/kg of 8.4% sodium
CASE: A health care provider prescribes bicarbonate IV to be administered over the
cefuroxime 30 mg/kg/day PO divided in next 4 hours. The client weighs 150 lb, and
equal doses every 12 hours for a child with a the pharmacy supplies the following IV
urinary tract infection. The child weighs 34
solution: 8.4% sodium bicarbonate in 1000 shift. Calculate the total net fluid balance for
mL of D5W with 150 mEq (150 mmol) of the shift.
sodium bicarbonate. At what rate in
milliliters per hour (mL/hr) should the nurse ANS: 890
set the infusion pump?
• Peritoneal dialysis allows waste products to
ANS: 227 be removed from the bloodstream through
the semipermeable membrane of the
peritoneum.
• Dialysate (ie, dialysis fluid) is infused into
the peritoneal cavity, retained for a
prescribed dwell time (eg, 20 minutes), and
then drained as dialysate outflow.
• For clients on peritoneal dialysis, fluid
balance should be tracked closely with daily
weights and strict intake and output
monitoring.
• Net fluid balance is calculated
by subtracting total output from total
intake.

CASE: An infant is experiencing respiratory

depression immediately after a vaginal
delivery using epidural analgesia with
morphine. The health care provider
prescribes 0.1 mg/kg naloxone IM to be
given STAT once. The client weighs 3600
grams and naloxone 0.4 mg/mL is
available. How many milliliters will the nurse
administer?

ANS: 0.9
CASE: A client with ascites had 5400 mL of
fluid removed during paracentesis. The
health care provider prescribes 8 g of
albumin IV per 1000 mL of fluid removed. If
the albumin is supplied as 25 g in 100-mL
bottles, how many mL will the nurse
administer?

ANS: 172.8

CASE: The nurse cares for a client receiving

intermittent peritoneal dialysis who is
prescribed strict intake and output monitoring
with calculation of net fluid balance each
CASE: A nurse is instructing the caregiver of
an 8-month-old client regarding
administration of oral amoxicillin. The client
is prescribed 25 mg/kg/day of amoxicillin in 2
divided doses for 5 days. The client weighs CASE: The nurse is preparing to administer
16.5 lb and the amoxicillin solution is an antibiotic to a child with pneumonia. The
prepared as 125 mg/5 mL. How many mL of prescription reads: 7.5 mg/kg every 24 hours
amoxicillin should the nurse instruct the divided into 2 doses, PO in liquid form. The
caregiver to administer for each dose? client weighs 78 lb. The pharmacy has
supplied the drug in 125 mg/5 mL. How
ANS: 3.75 many milliliters (mL) should the client receive
for each dose?

ANS: 5.3

CASE: A pediatric client weighing 66 lb is

prescribed ibuprofen 5 mg/kg by mouth CASE: An IV infusion of norepinephrine at 8
every 6 hr PRN for fever. It is available as mcg/min is prescribed for a client in
an oral solution of 20 mg/mL. How many shock. The concentration of norepinephrine
milliliters (mL) of ibuprofen should be given
is 4 mg in 250 mL of D5W. For how many
to the client per dose?
milliliters per hour (mL/hr) should the nurse
program the IV pump?
ANS: 7.5
ANS: 30
 ANS: 28

MAGNETIC RESONANCE
CHOLANGIOPANCREATOGRAPHY
CASE: A child with congenital heart disease • Magnetic resonance
weighing 44 lb is prescribed furosemide 1 cholangiopancreatography (MRCP) is a
mg/kg PO every 8 hours. It is available as noninvasive diagnostic test used to
an oral solution of 10 mg/mL. How many visualize the biliary, hepatic, and pancreatic
milliliters (mL) of furosemide should the ducts via MRI.
nurse administer to the client each dose? • MRCP uses oral or
IV gadolinium (noniodine contrast
ANS: 2 material) and is a safer, less-invasive
alternative to endoscopic retrograde
cholangiopancreatography to determine the
cause of cholecystitis, cholelithiasis, or
biliary obstruction.
• The nurse must assess
for contraindications before the
procedure, including the presence of
certain metal and/or electrical implants
(eg, aneurysm clip, pacemaker, cochlear
implant) or any previous allergy or reaction
to gadolinium .
• A client with a history of rash following prior
IV contrast administration should be
assessed to determine the type of contrast
that caused the reaction. Although allergies
to iodine-based contrast material are more
common, the nurse must rule out a
gadolinium allergy
• Pregnancy also is a contraindication for
MRCP as gadolinium crosses the placenta
CASE: The nurse is caring for a client who and may adversely affect the
has deep venous thrombosis and is fetus. Delayed/irregular menses may be a
prescribed a continuous IV infusion of normal variation in some clients; however,
heparin 25,000 units in 500 mL of D5W at delayed menses may indicate pregnancy
1300 units/hr. After 6 hours of the heparin and should be reported for further
infusion, the client's PTT is 44 seconds. The investigation prior to MRCP
nurse must adjust the infusion rate according • Many clients should be NPO for 4 hours
to the heparin drip protocol (shown in the prior to the procedure to allow better
exhibit). According to the protocol, at what visualization of the anatomical features.
rate in milliliters per hour (mL/hr) should the
nurse set the IV infusion pump?
• Smoking does not affect MRI visualization o Thoroughly dry the wound and
and is not a contraindication. surrounding skin using sterile gauze to
prevent maceration (breakdown) of
underlying tissues
SLING o Monitor the site for signs of
infection (eg, redness, warmth,
• A sling is used to support the shoulder purulent drainage)
after a fracture, dislocation, injury, or o Apply dry, sterile gauze over the
surgery. Commercially made slings are wound bed
used almost exclusively. They have a o Cover the gauze with an occlusive
sleeve that fits around the injured extremity sterile dressing to keep gauze in place
and extends above the elbow and and maintain asepsis. The covering
adjustable straps to provide a snug and should be applied without touching the
comfortable fit around the waist and neck. wound bed
• To prevent injury and provide proper
support of the affected extremity, the nurse • When performing a dry dressing change,
should evaluate the proper fit of the sling by the client must make sure that the
assessing for the following factors: bandaging materials applied (ie, gauze) are
dry. Sterile gauze moistened with sterile
o Elbow is flexed at 90 degrees to saline is used for wet-to-dry dressing
support the forearm, prevent swelling, changes and is not appropriate for a dry
and relieve shoulder pressure dressing change.
o Hand is held slightly above the level
of the elbow, through adjustment of
the neck strap, to prevent venous CLEAN CATCH URIN SPECIMEN
pooling and edema
o Bottom of the sling ends in the • A clean catch urine specimen is commonly
middle of the palm with the fingers performed in clients
visible, to be able to assess circulation, requiring urinalysis. The correct collection
sensation, and movement method for a female client is as follows:
o Sling supports the wrist joint with the
thumb facing upward or inward toward 1. Perform hand hygiene and open the
the body, to maintain proper alignment specimen container, leaving the sterile
o Skin irritation, which can occur under side of the collection lid
the sling and around the neck if the positioned upward to prevent
strap is too tight contamination.
2. Spread the labia using the index finger
DRY DRESSING CHANGE and the thumb of the nondominant hand
so that the specimen cup can be held
• Prior to discharge, the nurse must evaluate with the dominant hand.
the client's ability to perform home wound 3. Cleanse the vulva in a front-to-
care. When performing a simple dry back motion with provided antiseptic
dressing change, the client should: wipes, using a new towelette with each
wipe to prevent contamination.
o Don clean gloves and perform hand 4. Initiate the urinary stream to flush any
hygiene before and after removing the remaining microorganisms from the
old dressing urethral meatus before passing the
o Cleanse the wound bed using sterile container into the stream for the
saline (or a prescribed cleanser) by collection of 30-60 mL of urine.
moving from "clean" to "dirty," or from 5. Remove the specimen container from
the center of the wound outward the stream before the urinary flow
 ends and the labia are released to tubing to flush all blood in the tubing
prevent contamination. through with NS.
6. Replace the sterile cap without 9. Return the blood bag with the attached
contaminating it and repeat hand set-up to the laboratory after completion
hygiene. or dispose of in accordance with
hospital policy. Use new IV Y tubing
BLOOD TRANSFUSION set-up for the second unit of blood.

• The procedure for safe blood administration • Blood transfusions are commonly
includes the following: administered to clients experiencing anemia
or acute blood loss. To ensure client
1. Obtain a unit of blood from the blood safety during blood administration, the
bank and verify the blood product with nurse should:
type and crossmatch results and at least
2 client identifiers with another nurse at o Verify two client identifiers (eg,
the client's bedside. The blood is name, medical record number, date of
obtained and infused one unit at a time birth), the prescription, and the blood
2. Assess the client, obtain vital signs for products with another licensed health
baseline, and teach signs of a care provider
transfusion reaction and how to call for o Ensure that blood type and Rh
help. type are compatible. An Rh-positive
3. Use a Y tubing, prime with NS, and client can safely receive Rh-positive or
then clamp the NS side Rh-negative blood.
4. Spike the blood product, leaving the o Administer the blood via filtered
blood side of the Y tube open while tubing with normal saline to prevent
keeping the saline side clamped for clumping in the tube and hemolysis of
infusion. The saline is only used to red blood cells
prime the tubing and flush after the o Monitor vital signs during transfusion
infusion. It does not infuse per facility-specific protocol (eg, before
simultaneously. transfusion, 15 minutes after
5. Set the infusion pump to deliver blood transfusion begins, periodically).
over 2–4 hours as prescribed. Rapid o Transfuse blood products within 4
infusion of the blood puts the client at hours due to the risk for bacterial
greater risk for transfusion reaction and growth.
fluid volume overload.
6. Remain with the client for at least NG TUBE INSERTION
the 1st 15 minutes and watch for signs
of blood transfusion reaction, including • Steps for inserting a nasogastric tube
fever, chills, nausea, vomiting, pruritus, for gastric decompression include the
hypotension, decreased urine output, following:
back pain, and dyspnea. Stop the
transfusion immediately if a reaction 1. Perform hand hygiene and apply clean
occurs. The first 15 minutes of infusion gloves (no need for sterile gloves)
should be slow to watch for these 2. Place client in high Fowler's position
reactions. 3. Assess nares and oral cavity and select
7. Take another set of vital signs 15 naris
minutes after infusion starts and 4. Measure and mark the tube
continue in accordance with facility 5. Curve 4-6" tube around index finger and
policy. Always take a final set of vital release
signs after the infusion is complete. 6. Lubricate end of tube with water-soluble
8. On completion of the blood transfusion, jelly
open the saline side clamp of the Y
 7. Instruct client to extend neck back witnessed or highly suspected. The
slightly primary rescue intervention for adults
8. Gently insert tube just past and children over age 1 is abdominal
nasopharynx, aiming tip downward thrusts, known as the Heimlich
9. Rotate tube slightly if resistance is met, maneuver. This maneuver entails
allowing rest periods for client applying upward thrusts with a fist to the
10. Continue insertion until just above upper abdomen just beneath the rib
oropharynx cage. The upward action causes the
11. Ask client to flex head forward and diaphragm to forcefully expel air out of the
swallow small sips of water (or dry if airway, carrying the foreign body out with it.
NPO) • If the child is conscious and able to cough
12. Advance tube to marked point or make sounds, the nurse should ask the
13. Verify tube placement and anchor - child to forcefully cough before
use agency policy and procedure to intervening. These signs indicate a partial
verify placement by anchoring tube in obstruction still allowing airflow, which may
place and obtaining an abdominal x- be cleared with strong coughing. However,
ray. Aspirating gastric contents and any signs of respiratory distress (eg, stridor,
testing the pH may also give an inability to speak, weak cough, and
indication of placement (pH should be cyanosis) require immediate intervention.
5.5 or below). Auscultation of inserted • Back blows and chest thrusts are
air is acceptable for confirming tube appropriate interventions for a choking
placement initially, but is not definitive as infant under age 1. Older children require
it is not an evidence-based abdominal thrusts to clear an obstructed
method. Nothing may be administered airway.
through the tube until x-ray • Blind sweeping a child's mouth can force a
confirmation is obtained, or this may loosely obstructing object to fully block the
cause aspiration. airway or cause the object to fall farther into
the airway, requiring surgical removal.
• During NG tube insertion, the tube • This child is experiencing a blocked airway,
sometimes slips into the larynx or coils in which is a medical emergency that requires
the throat, which can result in coughing and intervention at the skill level of a
gagging. nurse. The nurse can ask a bystander to
• The nurse should withdraw the contact 911 while attempting to clear the
tube slightly and then stop or pause while airway. This differs from a situation such as
the client takes a few breaths. anaphylaxis, in which the nurse would
• After the client stops coughing, the nurse require epinephrine and would call 911 for
can proceed with advancement, asking the immediate assistance.
client to take small sips of water to facilitate
advancement to the stomach.
• The client should not be asked to swallow
during coughing or aspiration may occur. If
resistance or obstruction occurs during tube
advancement, the nurse should rotate the
tube while trying to advance it.
• If resistance continues, the tube should be
withdrawn and inserted into the other naris IFC
if possible

FOREIGN BODY ASPIRATION

• Foreign body aspiration is an emergency
that requires immediate intervention when
 CASE: 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?

• Obstruction (eg, clots, sediment),

kinking/compression of catheter tubing,
bladder spasms, and improper catheter size
can cause leakage of urine from the
insertion site of an indwelling urinary
catheter.
• The nurse's first action should be ANS: ADVISE THE STAFF NURSE TO
to assess for a mechanical DISCARD THE COLLECTED URINE
obstruction by inspecting the catheter SPECIMEN AND RECORD THE OUTPUT
tubing
• These interventions may alleviate • Urine specimens must be
obstruction: collected aseptically from the port located
on the catheter tubing of an indwelling
o Remove kinking or compression of the urinary catheter. Obtaining urine from a
catheter or tubing. collection bag is improper technique, and it
o Attempt to dislodge a visible
would not be considered a viable
obstruction by milking the specimen. In this case, the collected urine
tubing. This involves squeezing and should be measured and
releasing the full length of the tubing, discarded. Colonization and multiplication
starting from a point close to the client of bacteria within the stagnant urine in the
and ending at the drainage bag. collection bag may occur and cause
incorrect results. In addition, some urinary
drainage bags are impregnated with an
• If these interventions fail, the nurse should
antimicrobial agent to help prevent
then notify the health care provider (HCP)
catheter-associated urinary tract infections;
• Irrigation is usually avoided as pus or
these agents can also negatively affect the
sediment can be washed back into the
results of a urinalysis or culture.
bladder; however, it is sometimes
• To collect a urine specimen:
prescribed to relieve an obstruction to urine
flow. If there is a discrepancy in expected
1. Clean the collection port with an alcohol
urine output compared with fluid intake, a
swab
blockage is suspected and a bladder scan
2. Aspirate urine with a sterile syringe
is then performed to confirm the presence
3. Use aseptic technique to transfer the
of urine in the bladder.
specimen to a sterile specimen cup
• The client has the recommended size of
catheter and balloon for an adult male. The
MIXING REGULAR AND NPH INSULINS
HCP may prescribe removal and reinsertion
of a different-size catheter if other
measures fail to relieve obstruction. • CASE: A client with type 1 diabetes has a
prescription for 20 units of NPH insulin
daily at 7:30 AM and regular insulin
before meals, based on a sliding
URINE SPECIMEN COLLECTION FROM IFC
scale. At 7:00 AM, the client's blood
 glucose level is 220 mg/dL (12.2 mmol/L), vial. Multidose vials of regular insulin that
and the client's breakfast tray has have been contaminated with other insulins
arrived. What action should the nurse are unsafe for IV administration. When
take? drawing up multiple insulins, the nurse
• ANS: ADMINISTER 26 U OF NPH should:
MIXED WITH 6 U OF REGULAR
INSULIN IN THE SAME SYRINGE, 1. Clean both vial tops with alcohol
DRAWING UP THE REGULAR INSULIN swabs (Option 1).
FIRST 2. Inject air into the NPH insulin vial
without touching the needle to the
• Intermediate-acting insulins (NPH) can be solution (Option 4).
safely mixed with short-acting (regular) 3. Withdraw the needle from the NPH
and rapid-acting (lispro, aspart) insulins in insulin vial and inject air into the regular
one syringe (Option 4). Six units of regular insulin vial (Option 5).
insulin are needed to address the client's 4. Invert the regular vial and withdraw the
blood glucose reading (220 mg/dL [12.21 regular solution into the syringe (Option
mmol/L]) along with the scheduled 20 units 3).
of NPH insulin. 5. Insert the needle into the NPH insulin
• Prepare the mixed dose: vial and withdraw the solution

1. Inject the NPH insulin vial with 20 units

of air without inverting the vial or INTRADERMAL INJECTIONS
passing the needle into the solution.
2. Inject 6 units of air into the regular • Intradermal dermal injections deliver a
insulin vial and withdraw the dose, small amount of medication (0.1 mL) into
leaving no air bubble. the dermal layer of the skin, just under the
3. Draw NPH, totaling 26 units in one epidermis. This parenteral route is used to
syringe. Any overdraw of NPH into the perform allergy testing and tuberculosis
syringe will necessitate wasting the (TB) screening.
total quantity.
• The correct procedure for administering a
TB intradermal injection is as follows:
• Most long-acting insulins (eg, glargine,
detemir) are not suitable for mixing and 1. Choose a 1 mL tuberculin syringe with
typically are packaged in prefilled injection a 27-gauge 1/4 inch needle then don
pens. clean gloves – the syringe is calibrated
• The 2 insulins may be safely given together in hundredths of a millimeter and the
before the meal because regular insulin has intradermal needle is short enough to
a rapid onset of action, whereas NPH has a remain in the dermis with length range
slower onset but longer duration. of 1/4-5/8 inch
• The insulins can be given as 2 separate 2. Position the left forearm to face
injections; however, this increases client upward, and cleanse site that is a
discomfort and infection risk. hands width above the wrist – the left
• Regular insulin should be drawn first to arm is commonly used for TB testing;
avoid contaminating the regular insulin vial the forearm has little hair and
with NPH insulin (mnemonic – RN: Regular subcutaneous tissue and is readily
comes before NPH). accessible to observe a skin reaction.
• When drawing up multiple insulins, there is
a risk for contaminating the shorter-acting 3. Place non-dominant hand 1 inch below
vials with the longer-acting insulin, which the insertion site and pull skin
would slow the action of later doses downward so that it is taut – taut skin
withdrawn from the shorter-acting insulin
 makes it easier to insert the needle and 3. Administer oxygen if necessary to
promotes comfort. relieve dyspnea.
4. Notify the HCP or call an RRT to
4. Insert the needle almost parallel to skin
provide further resuscitation measures.
at a 10-degree angle with bevel up –
5. Stay with the client to provide
this is important as the medication can
reassurance and monitoring as the air
enter the subcutaneous tissue if the
trapped in the right atrium is slowly
angle is >15 degrees
absorbed into the bloodstream over the
5. Advance the tip of the needle through course of a few hours.
epidermis into dermis; outline of bevel
should be visible under the skin – • Flushing the lumen of a central venous
verify that the medication will be injected access device (central venous catheter
into dermis [CVC]) with normal saline is recommended
to assess patency before medication
6. Inject medication slowly while raising
infusion, prevent medication
a small wheal (bleb) on the skin – incompatibilities after infusion, and prevent
verify that the medication is being occlusion after blood sampling.
deposited into the dermis
• A 10-mL syringe is generally preferred for
7. Remove needle and do not rub the
flushing the lumen of a CVC
area – rubbing promotes leakage
through the insertion site and • The smaller the syringe, the greater the
medication deposition into the tissue. amount of pressure per square inch exerted
during injection, increasing the risk for
8. Circle the area with a pen to assess
damage to the CVC.
for redness and induration (according to
institution policy) – this delineates the • The "push-pause" method involves slowly
border for measurement of reaction. injecting normal saline into the CVC
CENTRAL VENOUS CATHETER catheter and stopping for any
resistance. Injecting against resistance can
• Leakage of more than 500 mL of air into a damage the CVC, which may result in
central venous catheter is potentially complications,
fatal. An air embolism in the small including embolism and malfunction. The
pulmonary capillaries obstructs blood nurse should always consult the specific
circulation. A central venous catheter leaks manufacturer guidelines and facility policy
air rapidly at 100 mL/sec. This client when caring for a CVC.
requires immediate intervention to prevent
further complications (eg, cardiac arrest, • A smaller syringe (eg, 1 mL, 3 mL) creates
death). The nurse should not delay more pressure, which increases the risk for
emergency treatment, not even to stop and damage to the CVC.
contact the HCP or the rapid response • A 30-mL syringe is unnecessarily large to
team (RRT). flush a CVC.
• Priority interventions for active or suspected
air embolism are as follows: CONDOM CATHETER

1. Clamp the catheter to prevent more air • Paraphimosis occurs when the
from embolizing into the venous uncircumcised male foreskin cannot be
circulation. returned (reduced) to its original position,
2. Place the client in after being pulled back (retracted) behind
Trendelenburg position on the left the glans penis, resulting in pain,
side, causing any existing air to rise and progressive swelling of the foreskin, and
become trapped in the right atrium. impaired lymph and blood flow.
• Paraphimosis can occur when a health care tone heard on percussion. Percussion is
worker accidentally leaves the foreskin in also intended to identify borders of organs
the retracted position for an extended that move with respiration (eg, liver,
period of time (eg, under a condom catheter spleen).
sheath). It is critical for the precepting • A client in pain from abdominal tenderness
nurse to intervene when the student nurse will likely take quick, shallow breaths, which
retracts the foreskin before applying the will change how far organs are displaced
condom catheter to avoid permanent and make it more difficult for the examiner
damage to the glans resulting from to identify true borders of organs.
impaired circulation
ENTERAL FEEDING
• The drainage tubing is attached to a leg
collection bag in a mobile client to enable Enteral feedings are given to provide nutrition
ambulation, prevent tube kinking, and to clients who are unable to take in nutrients by
facilitate gravity drainage. mouth. Placement verification is imperative
• A 1-2 in (2.5-5 cm) space should be left prior to initiating enteral feedings to prevent
between the tip of the penis and the end of complications such as aspiration. Lung
the condom to prevent penile irritation and aspiration can lead to pneumonia, acute
pooling of urine in the condom. respiratory distress syndrome, and abscess
• If the condom catheter is not self-adhesive, formation. Methods to verify the tube
elastic adhesive is used in a spiral fashion placement include the following:
to secure the device to the penis. Adhesive
tape may cause irritation and/or injury, and 1. Imaging - visualization of tube
should not be used. placement by x-ray is the standard
protocol to ensure proper placement
prior to initiating enteral tube feedings
ABDOMINAL ASSESSMENT 2. Gastric content pH testing - although
testing the pH of aspirated contents is
• Nursing assessments are generally an evidence-based method, it is typically
performed in order of least to most invasive. used to assess for displacement after
• To perform an abdominal assessment, the initial x-ray verification. It can also be
nurse places the client in the supine used to test the position of the tube prior
position to promote relaxation of the to each feed as the frequent x-rays
abdominal muscles. Standing on the right expose the client to radiation. Gastric
side of the client, the nurse makes a pH is usually acidic (<5) because of acid
visual inspection of the abdomen before secretion. pH ≥6 indicates bronchial
touching the client. secretions and incorrect placement.
• After inspection, the nurse auscultates the 3. Air auscultation - verification by
abdomen. Auscultation is performed next auscultating air is not an evidence-
because percussion and palpation may based method for placement
increase peristalsis, potentially leading the verification
nurse to make an erroneous interpretation
of bowel sounds. The nurse should lightly • After placement is verified, the nurse may
place the diaphragm of the stethoscope in flush the tube with water, administer
the right lower quadrant because high- prescribed medications, flush the tube
pitched bowel sounds are normally present again, and then prepare and deliver the
in this region. enteral feeding
• After auscultation, the nurse proceeds • A nasoenteric feeding tube is used for
to percussion. administration of continual or intermittent
• Palpation is performed last because it may enteral feedings and medications. The tube
induce pain, resulting in abdominal rigidity, is marked at the exit site (nare) with
guarding, and a change in indelible ink during the initial placement x-
respirations. This rigidity may affect the
 ray. The tube may have moved out of the • Some facilities no longer routinely check
correct position if its external length GRVs because recent evidence shows that
changes. If this occurs, the nurse should the procedure may not truly indicate
contact the health care provider (HCP) and aspiration risk and actually impairs calorie
request a prescription for a repeat x-ray to delivery.
determine tube location. Based on the x- • Regardless of GRV checks, the nurse
ray results, enteral feeding may be should closely monitor clients
resumed or the HCP may prescribe for symptoms of intolerance (eg,
insertion of a new tube according to abdominal distension, nausea/vomiting),
institution policy which may indicate that feedings should be
• Even if bedside methods to determine held or reduced in volume.
placement are used (eg, gastric aspirate pH • Aspirated GRV should be returned to the
and appearance), advancing the tube to the stomach. If acidic gastric juices are
original marking does not guarantee correct repeatedly discarded, there is risk for
placement; these methods are not accurate hypokalemia and metabolic alkalosis.
indicators. Tube feedings should not be • (Gastric pH should be acidic (pH ≤5). A pH
resumed after tube dislodgment without x- ≥6 requires x-ray confirmation of tube
ray verification of correct placement. placement. Newly inserted nasogastric
• A prescription for hand mitts to keep a tubes also require x-ray confirmation before
confused client from disrupting enteral feedings are initiated.
nutrition may be appropriate if other less
restrictive interventions (eg, keeping tubing
out of client's sight, one-on-one sitter) are • Failure to correctly
ineffective or unavailable. However, this administer medications through feeding
should not be the nurse's next action. tubes (eg, nasogastric, gastrostomy) can
• The guide wire (stylet) is secured before result in obstruction of the tube, reduced
tube insertion and remains in place until medication absorption or efficacy, and
placement is verified by x-ray. Once medication toxicity. Before administering
removed, the guide wire should never be medications through a feeding tube, the
reinserted while the tube is in place as it nurse should determine if any of the
can protrude and damage both the tube medications are available in a liquid
and the client's mucosa. form because liquid medications are less
• When administering bolus enteral likely to clog the tube
feedings, the nurse should elevate the
head of the bed to 30-45 degrees (semi- • Medications should be crushed, dissolved,
Fowler position) and keep it elevated for 30- and administered separately to prevent
60 minutes afterwards to decrease interactions (eg, chemical reactions)
aspiration risk. between medications or interference with
• Many institutions require the nurse to hold absorption.
feeding if the client must remain supine (eg, • In addition, a feeding tube should
diagnostic tests). be flushed before and after each
• Feeding tubes should be flushed before medication is given to avoid potential drug
and after feedings to keep the tube patent interactions and ensure tube patency
• Gastric residual volumes (GRVs) are
traditionally checked every 4 hours with • When using a feeding tube, each
continuous feeding or before each bolus medication should be administered
feeding. Per facility policy, enteral feedings individually to prevent interactions between
may be held for high GRV (eg, >500 mL) to medications.
reduce aspiration risk. Low GRV indicates • Medications mixed with enteral feedings
that the client is tolerating feedings well may form a thick consistency and clog the
tube.
HEART AUSCULTATION congenital hypothyroidism,
phenylketonuria).
• Proper technique is essential for minimizing
discomfort and preventing complications
and includes:

o Select a location on the medial or

lateral side of the outer aspect of the
heel. Avoid the center of the heel to
prevent accidental insult to the
calcaneus. Puncture should not occur
over edematous or infected skin.
o Warm the heel for several minutes with
a warm towel compress or approved
single-use instant heat pack to promote
vasodilation. Cleanse the intended
puncture site with alcohol. Sucrose
and nonnutritive sucking on a pacifier
may reduce procedural pain.
• Aortic stenosis (AS) is a type of valvular o Use an automatic lancet, which
heart disease characterized controls the depth of puncture. Lancing
by narrowing of the aortic valve opening, the heel too deeply can result in
which limits the left ventricle's ability to eject penetration of the calcaneus bone,
blood into the aorta. leading to osteochondritis or
• AS may occur from hardening (ie, osteomyelitis.
calcification) of the valves, congenital heart
disorders, or inflammation. If left untreated, • An acceptable alternate method of blood
AS may result in heart failure and collection in the neonate is venipuncture (ie,
pulmonary hypertension as compensatory drawing blood from a vein). Venipuncture
mechanisms fail. is considered less painful and often
• When assessing a client with AS, the nurse requires fewer punctures to obtain a
should auscultate in the aortic sample, especially if a larger volume is
area (ie, second intercostal space at the needed
right sternal border) for a loud, systolic
ejection murmur heard following the first
heart sound. TRACHEOSTOMY CARE
• The aortic area, rather than directly over the
heart valve, is the preferred location for • When performing tracheostomy care, the
auscultation as the heart sounds travel in nurse follows institution policy and observes
the direction the blood flows. Additional principles of infection control and client
clinical manifestations of aortic stenosis safety. Sterile technique is used to prevent
include chest pain, shortness of breath, infection of the lower airway. The steps for
and/or syncope that are worsened by performing the procedure for a client with
exertion. a disposable inner cannula include the
following:

NEONATAL HEEL STICK 1. Gather supplies to the bedside, then

place client in semi-Fowler's position,
• The neonatal heel stick (heel lancing) is if not contraindicated, to promote lung
used to collect a blood sample to assess expansion and oxygenation and prevent
capillary glucose and perform newborn aspiration of secretions.
screening for inherited disorders (eg,
 2. Don personal protective • Clients usually cough as the catheter enters
equipment (mask, goggles, and clean the trachea, and this helps loosen
gloves) to maintain universal secretions. The catheter should be
precautions. Auscultate lungs and advanced until resistance is felt and then, to
suction secretions if necessary. prevent mucosal damage, retracted 1 cm
3. Remove soiled dressing and also before applying suction.
remove clean gloves.
4. Don sterile gloves; remove old PULSUS PARADOXOSUS
disposable cannula and replace with
a new one. While stabilizing the back • Muffled heart tones in a client with
plate with the nondominant hand, unlock pericardial effusion can indicate the
(unclip) the old cannula with the development of cardiac tamponade. This
dominant hand; remove gently by pulling results in the build-up of fluid in the
it out in line with its curvature; pick up pericardial sac, which leads to compression
the new cannula, touching only the outer of the heart.
locking portion (to prevent • Cardiac output begins to fall as cardiac
contamination and maintain asepsis); compression increases, resulting
insert; and lock (clip) into place. in hypotension.
5. Clean around stoma with sterile • Additional signs and symptoms of
water or saline, dry and replace tamponade include tachypnea,
sterile gauze pad to remove dried tachycardia, jugular venous distension,
secretions, and dry around stoma well to narrowed pulse pressure, and the presence
limit the growth of of a pulsus paradoxus.
microorganisms. Some tracheostomy • Pulsus paradoxus is defined as an
tubes are sutured in place and do not exaggerated fall in systemic BP >10 mm Hg
require a dressing. If secretions are during inspiration.
copious, apply a dressing. • The procedure for measurement of
pulsus paradoxus is as follows:
• The process of suctioning a client's airway
removes oxygen in addition to the 1. Place client in semirecumbent position
secretions; therefore, the client should 2. Have client breathe normally
be preoxygenated with 100% O2, and 3. Determine the SBP using a manual BP
suction should be applied for no more than cuff
10 seconds during each pass to prevent 4. Inflate the BP cuff to at least 20 mm Hg
hypoxia above the previously measured SBP
• The nurse must wait 1-2 minutes between 5. Deflate the cuff slowly, noting the first
passes for the client to ventilate to prevent Korotkoff sound during expiration along
hypoxia with the pressure
• In addition, deep rebreathing should be 6. Continue to slowly deflate the cuff until
encouraged. you hear sounds throughout inspiration
• The suction catheter should be no more and expiration; also note the pressure
than half the width of the artificial airway 7. Determine the difference between the 2
and inserted without suction. measurements in steps 5 and 6; this
• The nurse should don sterile gloves if the equals the amount of paradox
client does not have a closed suction 8. The difference is normally <10 mm Hg,
system in place. Suction should be set but a difference >10 mm Hg may
at medium pressure (100-120 mm Hg for indicate the presence of cardiac
adults, 50-75 mm Hg for children) as tamponade.
excess pressure will traumatize the mucosa
and can cause hypoxia.
VENIPUNCTURE equipment, and choose a different site for
specimen collection
• A tourniquet is applied 3-5 inches above the
• (Because the pain and numbness during
desired puncture site for no longer than 1
venipuncture indicate a nerve injury, the
minute when looking for a vein. If longer
nurse should reattempt the specimen
time is needed, release the tourniquet for at
collection using a different
least 3 minutes before reapplying.
site. Reattempting at the same site with a
• Prolonged obstruction of blood flow by the
smaller-gauge needle or from a different
tourniquet can change some test results.
angle could cause nerve damage.
• Pulsating bright red blood indicates that an
artery was accessed. If this happens, the • Reassurance may help calm an anxious
needle should be removed immediately and client, and stabilization may help prevent
pressure should be applied for at least 5 injury if a client attempts to withdraw the
minutes, followed by a pressure dressing to arm during routine venipuncture. However,
prevent a hematoma. this client has nerve pain, which indicates
• Skin preparation involves cleaning using an that the attempt should be stopped
antiseptic solution and friction and allowing immediately to prevent nerve damage.
the skin to air dry. Remaining solution may
hemolyze and/or dilute the blood sample.
• Traditionally, alcohol (alone or with THORACENTESIS
povidone iodine) is applied in a circular
motion, from insertion site outward (clean to • Thoracentesis is commonly used to treat
dirty). pleural effusion. The health care provider
(HCP) will prepare the skin, inject a local
• Current research suggests that the most
anesthetic, and then insert a needle
effective method is applying chlorhexidine
between the ribs into the pleural space
(2%) in a back and forth motion, followed by
where the fluid is located.
adequate drying time.
• A complication of thoracentesis
• The veins on the ventral aspect of the wrist
is pneumothorax, which occurs when the
are located near nerves, resulting in painful
needle goes into the lung and causes the
venipuncture and a higher risk of nerve
lung to slowly deflate, like a balloon with a
injury. There is also an increased risk of
small hole in it. Bleeding is another, yet
arterial access on the ventral aspect of the
less common, complication of the
wrist, and so this site should be avoided.
procedure.
• The filled tube should be gently inverted 5-
• Signs of pneumothorax include increased
10 times to mix anticoagulant solution with
respiratory rate, increased respiratory effort,
the blood. Vigorously shaking the tube can
respiratory distress, low oxygen saturation,
cause hemolysis and false results.
and absent breath sounds on the side
• The preferred site for venipuncture when where the procedure was done (where the
collecting blood specimens is the lung is collapsed).
antecubital fossa's median cubital vein. • Tension pneumothorax may also develop,
with tracheal shift to the unaffected side,
• The basilic vein lies close to the brachial severe respiratory distress, and
nerve and artery. When severe, shooting cardiovascular compromise. Altered level
pain radiates down a client's arm during of consciousness may occur due to
venipuncture, nerve injury may be decreased oxygenation and blood flow to
occurring. The client may also report the brain.
feelings of "pins and needles" or
• A tension pneumothorax may be prevented
numbness at and/or near the venipuncture by early detection of pneumothorax through
site. If this occurs, the nurse should
appropriate monitoring.
promptly withdraw the needle, obtain new
• Infection would be a later complication CLEANSING ENEMA
(occurring a few days after the procedure),
• Cleansing enemas (eg, normal saline,
so monitoring temperature is not required
soapsuds, tap water) relieve constipation by
during the initial postprocedure period.
stimulating intestinal peristalsis. When
• Urine output should not be affected by
administering an enema, appropriate
thoracentesis or the drugs administered for
interventions include:
this procedure.
o Place the client in a left lateral position
with the right knee flexed (ie, Sims
ORTHOSTATIC VITAL SIGNS position) to promote flow of the enema
• Orthostatic vital signs help assess the into the colon
body's ability to compensate o Hang the enema bag no more than 12
hemodynamically during postural in (30 cm) above the rectum to avoid
changes. overly rapid administration.
• Changing position normally triggers o Lubricate the enema tubing tip and
vasoconstriction in the extremities to gently insert 3-4 in (7.6-10 cm) into the
promote venous return. Without this rectum.
response, hypotension and subsequent o Direct the tubing tip toward the
hypoperfusion of internal organs and the umbilicus (ie, anteriorly) during
brain occur. insertion to prevent intestinal
• Clients with impaired compensatory perforation
mechanisms (eg, hypovolemia, sepsis) may o Encourage the client to retain the
exhibit orthostatic hypotension, in which enema for as long as possible (eg, 5-10
hypotension and/or neurologic impairment minutes)
(eg, syncope) occur with position o Open the roller clamp on the tubing to
change. This increases the client's risk for allow the solution to flow in by
falls. gravity. If the client reports abdominal
• Orthostatic vital signs involve measuring cramping, use the roller clamp to slow
the client's blood pressure (BP) and heart the rate of administration
rate in the supine, sitting, and standing
positions. Each measurement should be • Enemas are administered at room
obtained after maintaining each position for temperature or warmed, as cold enema
2 minutes. solutions cause intestinal spasms and
• If any position change produces painful cramping. Enemas may be warmed
decreased systolic BP ≥20 mm Hg, by placing the container of solution in a
decreased diastolic BP ≥10 mm Hg, basin of hot water.
and/or increased pulse ≥20/min from supine TRIPLE LUMEN CATHETER
values, the nurse should discontinue • Catheter occlusion is the most common
assessment, place the client in a recumbent complication of central venous access
position, and notify the health care provider devices. Kinked tubing, catheter
• It is unsafe to assist the client to a standing malposition, medication precipitate, or
position after identifying orthostatic thrombus can occlude the lumen,
hypotension, as a syncopal event may preventing the ability to flush or aspirate
occur and the client may fall. blood.
• Positioning the client in reverse • The nurse should first assess for
Trendelenburg position and reassessing BP mechanical, nonthrombotic problems by:
at a different site in the supine position are
unnecessary and delay treatment of 1. Repositioning the client (eg, head,
orthostatic hypotension. arm) as the catheter tip may be resting
against a vessel wall (
 2. Assessing IV tubing for clamps, kinks, simultaneously, for blood draws, and for
and precipitate hemodynamic monitoring

• The nurse should then attempt to flush the

device again. If the occlusion remains, the PHLEBOTOMY
nurse should not flush against resistance as
applying force may damage the catheter or • When performing phlebotomy, clean the
dislodge a thrombus. Instead, the nurse site, "fix" or hold the vein taut, and then
should contact the health care provider insert the needle bevel up at a 15-degree
(HCP), who may prescribe medication (ie, angle (no steeper than 30 degree). Some
alteplase) to dissolve a thrombus or fibrin recommend bevel down for children. This
sheath. will help prevent going through the vein
completely.
• Most needleless connector manufacturers
recommend flushing with normal • The Infusion Nurses Society (INS) identifies
saline. Some facilities may use heparinized the standard of care as no more than 2
saline flushes; the nurse should follow HCP attempts by any 1 individual. If the nurse
prescriptions and institution is unable to successfully draw blood after 2
guidelines. Heparin flushes should be at attempts, a phlebotomist or a different
the lowest acceptable dose (eg, 10 nurse should be asked to complete the
units/mL) to prevent heparin-induced blood draw.
thrombocytopenia. • The affected side of a client who has had a
• Flushing with a syringe smaller than 10 mL mastectomy (especially with lymph node
causes increased intraluminal pressure and removal) should not be used. It places the
may damage the catheter. client at risk for infection and
lymphedema.
• The nurse should rule out a mechanical
problem before notifying the HCP. • An arm without IV infusion is preferred. If it
is necessary to use the arm with the IV
• A central line or central venous
infusion, the specimen should be collected
catheter (CVC) is inserted by the health
from a vein several centimeters below
care provider in a "central" vein (eg,
(distal to) the point of IV infusion, with the
subclavian, internal jugular, femoral) and is
tourniquet placed in between.
used to administer fluids, medications, and
parenteral nutrition and for hemodynamic • The finger specimen should be obtained
monitoring. from the third or fourth finger on the side of
the fingertip, midway between the edge and
• Proper hand hygiene should be performed
midpoint. The puncture should be made
when caring for a CVC to prevent infection,
perpendicular to the fingerprint
and nonsterile gloves should be worn to
ridges. Puncture parallel to the ridges
protect the nurse from blood or body fluids
tends to make the blood run down the
at the port site as one or more lumens are
ridges and will hamper collection.
often used to draw blood
• A heel stick collection on an infant should
• The Centers for Disease Control and
be done on the plantar surface.
Prevention recommend that catheter hubs
always be handled aseptically to prevent
catheter-associated infections. The hubs
should be disinfected with a hospital- INCENTIVE SPIROMETRY
approved antiseptic (eg, 70% alcohol sterile • Incentive spirometry is recommended in
pads; > 0.5% chlorhexidine with alcohol; postoperative clients to prevent
10% povidone-iodine). Always allow the atelectasis associated with incisional
antiseptic to dry before using the hub/port pain, especially in upper abdominal
• CVCs may have multiple lumens. These incisions (close to the diaphragm).
are used to administer incompatible drugs
• Adequate pain medication should be notifying hospital staff of
administered before using the incentive necessary mastectomy precautions (eg,
spirometry. no blood pressure measurements,
• Guidelines recommend 5-10 breaths per venipuncture, or IV lines)
session every hour while awake. Volume- • In general, venipuncture is contraindicated
oriented or flow-oriented sustained maximal in upper extremities affected by:
inspiration (SMI) devices can be used.
• The client instructions for using a volume- o Weakness
oriented SMI device include: o Paralysis
o Infection
1. Assume a sitting or high Fowler o Arteriovenous fistula or graft (used for
position, which optimizes lung hemodialysis)
expansion, and exhale normally o Impaired lymphatic drainage (prior
2. While holding the device at an even mastectomy)
level, seal the lips tightly on the
mouthpiece to prevent leakage of air • The stylet should be advanced until blood
around it return is seen (approximately ¼ inch). If
3. Inhale deeply through the mouth until advanced fully, the stylet may penetrate the
the piston is elevated to the posterior wall of the vein and cause a
predetermined level of tidal hematoma.
volume. The piston is visible on the • Keeping the affected arm in a dependent
device and helps provide motivation. position for a long time can increase
4. Hold the breath for at least 2-3 lymphedema. The client should be
seconds (up to 6 seconds) as this reminded that raising the limb helps
maintains maximal inhalation drainage.
5. Exhale slowly to prevent • The client's medical history should be
hyperventilation reviewed prior to starting an IV line so that
6. Breathe normally for several breaths the nurse can identify any contraindications
before repeating the process to specific anatomical sites.
7. Cough at the end of the session to help • Lymph node removal during
with secretion expectoration a mastectomy may affect lymphatic fluid
drainage on the affected side and
VENIPUNCTURE cause lymphedema or other complications
such as infection, venous
• A modified radical mastectomy includes thromboembolism, or trauma to the affected
removal of axillary lymph nodes that are arm.
involved in lymphatic drainage of the • The nurse
arm. Any trauma (eg, IV extravasation) to must avoid any needlesticks, IV
the arm on the operative side can result insertions, or blood pressure
in lymphedema, characterized by painful measurements in the affected arm
and lengthy swelling, as normal lymphatic • The nondominant side is preferred when no
circulation is impaired by medical contraindications exist. However,
scarring. Therefore, starting an IV line in in this case, the right forearm is best
this arm is contraindicated. because the client had a left-sided
• The nurse should insert the IV line into mastectomy
the most distal site of the unaffected side. • Other considerations when selecting IV
• For client safety, it is also important sites include avoidance of areas that have
to ensure documentation of the obstructed blood flow, dialysis sites, areas
mastectomy history, place a restricted distal to old puncture sites, bruised areas,
extremity armband on the affected arm, painful areas, or areas with skin conditions
and place a sign above the client's bed or signs of infection.
• The antecubital space should be avoided to end it at the same hour the next
when possible (except for emergency morning after the morning voiding
insertion) as it inhibits mobility and may be • To start the collection period, the nurse
positional. asks the client to void and discards this
specimen (it is not added to the collection
container). The 24-hour period starts at the
URINE DIPSTICK time of the client's first voiding.
• The protein test pad measures the amount MODIFIED THREE-POINT GAIT
of albumin in the urine. Normally, there will • Clients prescribed crutches after a
not be detectable quantities. musculoskeletal injury must be educated on
• Albumin is smaller than most other proteins appropriate device use to facilitate
and is typically the first protein that is seen independent ambulation, promote wound
in the urine when kidney dysfunction begins healing, and prevent reinjury.
to develop.
• Proteinuria is characterized by elevated • A common method used to climb stairs is
urine protein and can be an early sign of the modified three-point gait ("leading
kidney disease. Occasional loss of up to with the good leg"), which is used to
150 mg/day of protein in the urine, which prevent weight-bearing on the injured leg.
may reflect as negative or trace protein on
• Nurses should instruct clients with crutches
a dipstick, is typically considered normal
to use the following steps to ascend the
and usually does not require further
stairs with the modified three-point gait:
evaluation.
• Common benign causes of transient 1. Assume the tripod position (ie, crutch
proteinuria include fever, strenuous stance) and place body weight on the
exercise, and prolonged standing. crutches while preparing to move the
unaffected leg.
TIMED URINE COLLECTION TESTS
2. Place the unaffected leg (ie, good leg)
• Timed urine collection tests are usually
onto the step.
done to assess kidney function and
measure substances excreted in the urine 3. Transfer body weight from the
(eg, creatinine, protein, uric acid, crutches to the unaffected leg and then
hormones). These tests require the use the unaffected leg (ie, good leg) to
collection of all urine produced in raise the body up onto the step.
a specified time period (a crucial step) to
4. Advance the affected leg and the
ensure accurate test results. The proper
crutches together up the step.
container (with or without preservative) for
any specific test is obtained from the 5. Realign the crutches with the unaffected
laboratory. The collection container must leg on the step before repeating the
be kept cool (eg, on ice, refrigerated) to process.
prevent bacterial decomposition of the
urine.
• Not all of the client's urine was saved during PULSE OXIMETER READING
the collection period. Therefore, the nurse
or UAP must discard the urine and • A pulse oximeter is a noninvasive device
container and restart the specimen that estimates arterial blood oxygen
collection procedure. saturation by using a sensor attached to
• Although a 24-hour urine collection can the client's finger, toe, earlobe, nose, or
begin at any time of the day after the client forehead.
empties the bladder, it is common practice • The sensor (reusable clip or disposable
to start the collection in the morning after adhesive) contains light-emitting and light-
the client's first morning voiding and sensing components that measure the
 amount of light absorbed by oxygenated taken along (in purse, pocket,
hemoglobin. Because the sensor estimates backpack) when the client leaves home
the value at a peripheral site, the pulse o The EpiPen should be given when the
oximeter measurement is reported as blood client first notices any anaphylactic
oxygen saturation (SpO2). symptoms, such as tightening or
• Normal SpO2 for a healthy client is 95%- swelling of the airway, difficulty
100%. Any factor that affects light breathing, wheezing, stridor, or shock
transmission or peripheral blood o The injection should be given in
flow can result in a false reading. Common the mid-outer thigh and can be given
causative factors of falsely low through clothing
SpO2 include: o The client should receive emergency
care as soon as possible by calling 911
• Dark fingernail polish or artificial acrylic or going to the emergency department
nails to monitor for further problems
• Hypotension and low cardiac output (eg,
heart failure) INTRAMUSCULAR INJECTIONS
• Vasoconstriction (eg, hypothermia,
• Intramuscular (IM) injections (eg,
vasopressor medications)
hepatitis B vaccine, vitamin K) are
• Peripheral arterial disease
commonly administered
to newborns shortly after birth or before
discharge.
• The vastus lateralis muscle in the
EPIPEN
anterolateral middle portion of the thigh is
the preferred site for IM injections in
• The EpiPen is designed to be
newborns (age <1 month) and infants (age
administered through clothing with a
1-12 months).
swing and firm push against the mid-outer
• The deltoid muscle is an inappropriate
thigh until the injector clicks.
injection site for newborns due to
• The position should be held for 10
inadequate muscle mass
seconds to allow the entire contents to be
• For IM injections, the needle length should
injected
be ⅝ inch for newborns and ⅝ to 1 inch for
• The site should be massaged for an
infants; these lengths are adequate for
additional 10 seconds. Timing is
reaching the muscle mass while avoiding
essential in the delivery of epinephrine
underlying tissues (eg, nerves, bone). A
during an anaphylactic reaction.
22- to 25-gauge needle is appropriate for
• The nurse should administer the medication
clients age <12 months.
immediately on the playground without
removing the child's clothing. Any delays
can cause client deterioration and make
FEMALE IFC INSERTION
maintenance of a patent airway difficult
• The EpiPen should be injected into the mid- • Steps for indwelling urinary catheter
outer thigh, not the upper arm. insertion for the female client include:
• A critical part of self-care for a person with
a history of anaphylactic reaction is the use o Position the client supine with knees
of emergency epinephrine injection flexed and hips slightly externally
(EpiPen or EpiPen Jr). The client and/or rotated.
caregiver should be taught the following o Perform hand hygiene and open a
principles: sterile catheterization kit
o Apply sterile gloves and place a
o The EpiPen should always be available sterile drape underneath the client's
for emergency use and so should be buttocks
 o Remove the protective covering from 2. Move the cane next, while bearing
the catheter, lubricate the catheter tip, weight on the stronger leg
and pour antiseptic solution over cotton 3. Finally, move the weaker leg
balls or swab sticks while maintaining
sterility of gloves and sterile field. • To remember the order, use the mnemonic
o Use the nondominant hand to "up with the good and down with
gently spread the labia. The the bad." The cane always moves before
nondominant hand is the weaker leg.
now contaminated
o Use the dominant (sterile) hand to
cleanse the labia and urinary meatus PERIPHERAL ARTERIAL PULSES
with antiseptic-soaked cotton balls or
swab sticks. Cleanse in • The DP pulse is located on the top or dorsal
an anteroposterior direction (from the part of the foot.
clitoris toward the anus). Use a new • The nurse should compare the
swab for each swipe to avoid characteristics of the arteries on the right
transferring bacteria between and left extremities simultaneously to
areas. Cleanse the labia majora first, determine symmetry.
then the labia minora, • The force of the pulse should be rated on
and lastly the urinary meatus the following scale.
o Use the dominant hand to insert the
catheter until urine return is 0 Absent
visualized in the tubing (usually 2-3
inch [5-7.6 cm]), and then advance it an
additional 1-2 inch (2.5-5 cm) 1+ Weak
o Hold the catheter in place with the
nondominant hand, and then use the
2+ Normal
dominant hand to inflate the balloon.

CANE Increased, full,

3+
bounding
• To prevent falls after a total knee
replacement, clients should use a cane to
provide maximum support when climbing OROPHARYNGEAL AIRWAY
up and down any stairs. Clients should • An oropharyngeal airway (OPA) is a
hold the cane on the stronger side and temporary, artificial airway device used to
move the cane before moving the weaker prevent tongue displacement and tracheal
leg, regardless of the direction. Clients obstruction in clients who are sedated or
must also keep 2 points of support on the unconscious.
floor at all times (ie, both feet, foot and • As consciousness and the ability to protect
cane). the airway return, the client will often cough
• When descending stairs, the client should: or gag, indicating a need to remove the
OPA; clients may also independently
1. Lead with the cane remove or expel the OPA.
2. Bring the weaker leg down next (in this • Nurses caring for a client with an OPA must
client, it is the left leg) ensure that the device is easily
3. Finally, step down with the stronger leg removable from the client's mouth, as an
obstructed (eg, taped) OPA may cause
• When ascending stairs, the client should: choking and aspiration
• The OPA should be inserted with the distal
1. Step up with the stronger leg first end pointing upward toward the roof of the
 mouth to prevent displacement of the within the last 5-10 years, depending on the
tongue and obstruction of the trachea. contamination level of the wound.
• Once the OPA reaches the soft palate (eg, • Wounds should be cleaned from the least
back of the mouth), the nurse rotates the to the most contaminated area to prevent
OPA tip downward toward the esophagus, recontamination.
which pushes the tongue forward and • A 10-mL syringe would require frequent
maintains airway patency. refilling; a larger syringe is more
• Appropriate OPA size should be measured appropriate. The narrow lumen of a 27-
prior to insertion, as inappropriate size gauge needle would provide excessive
could push the tongue back and cause irrigation pressure.
airway obstruction.
• The OPA should be measured with the
flange next to the client's cheek. With HEARING AID
correct sizing, the OPA curve will reach the
jaw angle. • Proper use and care of hearing aids is
essential to the success of hearing aid
therapy and is associated with improved
outcomes. Proper hearing aid use and care
WOUND IRRIGATION
include:
• Before an open wound is
o Minimize distracting sounds (eg,
closed, irrigation is performed to wash out
television, radio) during conversation to
debris and bacteria to ensure appropriate
enhance effectiveness
wound healing. This is important for
wounds obtained in an outdoor environment o Turn the volume off prior to insertion,
(eg, playground) as contamination with soil then gradually turn up the volume to a
or dirt greatly increases the risk of comfortable level
infection. o To adjust to the new hearing aids,
• To perform wound irrigation: initially wear them for a short time (eg,
20 minutes) and gradually
o Administer the analgesic 30-60 minutes increase length of wear time.
before the procedure to allow o Do not wear the hearing aids when
medication to reach therapeutic effect using hair dryers or heat lamps.
o Don a gown and mask with face shield
o Regularly check that the battery
to protect from splashing fluid and
compartment is clean, the batteries are
sterile gloves to maintain surgical
inserted correctly, and the compartment
asepsis and prevent infection.
is shut before insertion
o Fill a 30- to 60-mL sterile irrigation
syringe with the prescribed irrigation o Remove the battery (if possible) at night
solution. and when the aid is not in use to extend
o Attach an 18- or 19-gauge needle or battery life.
angiocatheter to the syringe and hold 1
in (2.5 cm) above the area. • Each aid must be cleaned with a soft
o Use continuous pressure to flush the cloth. Hearing aids should not be
wound, repeating until drainage is clear immersed in water, as this can damage the
o Dry the surrounding wound area to electrical components.
prevent skin breakdown and irritation. • Store hearing aids in a safe, dry place when
not in use. This will help prevent the
• Immunization history is reviewed to hearing aids from becoming lost or
determine tetanus vaccination status damaged.
• Typically, a tetanus vaccination is
administered if the client has not had one
EXTRAVASATION assisting with a lumbar puncture includes
the following:
• Extravasation is the infiltration of a drug
into the tissue surrounding the vein. 1. Verify informed consent
• Norepinephrine (Levophed) is a 2. Gather the lumbar puncture tray and
vasoconstrictor and vesicant that can cause needed supplies
skin breakdown and/or necrosis if 3. Explain the procedure to older child and
absorbed into the tissue. adult
• Pain, blanching, swelling, and redness are 4. Have client empty the bladder
signs of extravasation. Norepinephrine 5. Place client in the appropriate position
should be infused through a central line (eg, side-lying with knees drawn up and
when possible. However, it may be infused head flexed or sitting up and bent
at lower concentrations via a large forward over a bedside table)
peripheral vein for up to 12 hours until 6. Assist the client in maintaining the
central venous access is established. proper position (hold the client if
• The nurse should implement the following necessary)
interventions to manage norepinephrine 7. Provide a distraction and reassure the
extravasation: client throughout the procedure
8. Label specimen containers as they are
o Stop the infusion immediately and collected
disconnect the IV tubing 9. Apply a bandage to the insertion site
o Use a syringe to aspirate the 10. Deliver specimens to the laboratory
drug from the IV catheter; remove the
IV catheter while aspirating. CHEST TUBE REMOVAL
o Elevate the extremity above the heart
to reduce edema • A chest tube is removed when drainage is
o Notify the health care provider and minimal (<200 mL/24 hr) or absent, an air
obtain a prescription for the leak (if present) is resolved, and the lung
antidote phentolamine (Regitine), a has reexpanded. The general steps for
vasodilator that is injected chest tube removal include:
subcutaneously to counteract the
effects of some adrenergic agonists 1. Premedicate the client with
(eg, norepinephrine, dopamine) analgesic (eg, IV opioid, nonsteroidal
anti-inflammatory drug [ketorolac]) 30-
• The nurse should not flush the infiltrated IV 60 minutes before the procedure to
site or use it for further drug promote comfort as evidence indicates
administration. Although new IV access that most clients report significant pain
must be obtained, access should be during removal
established ideally through a central line or 2. Provide the health care provider (HCP)
on an unaffected extremity. with sterile suture removal equipment
3. Instruct the client to breathe in, hold it,
and bear down (Valsalva
LUMBAR PUNCTURE maneuver) while the tube is removed to
decrease the risk for a
• A lumbar puncture (spinal tap) is a sterile
pneumothorax. Most HCPs use this
procedure used to gather a specimen of
technique to increase intrathoracic
cerebrospinal fluid (CSF) for diagnostic
pressure and prevent air from entering
purposes (eg, meningitis). A needle is
the pleural space
inserted into the vertebral spaces between
4. Apply a sterile airtight occlusive
L3 and L4 or L4 and L5, and a sample of
dressing to the chest tube site
CSF is drawn. The nurse's role when
immediately; this will prevent air from
entering the pleural space
 5. Perform a chest x-ray within 2-24 hours 24 HOUR URINE COLLECTION
after chest tube removal as a post-
procedure pneumothorax or fluid • A 24-hour urine is collected to
accumulation usually develops within evaluate Cushing syndrome (a condition
this time frame. that results from chronic increased
corticosteroids). The urine is tested for free
cortisol, and results >80-120 mcg/24 hr
• The client should be placed in semi-
(220-330 nmol/day) indicate that Cushing
Fowler's position or on the unaffected side
syndrome is present. Instructions for
to promote comfort and facilitate access for
collecting a 24-hour urine are as follows:
tube removal.
o Use a dark jug containing a special
powder (obtained from the lab) to
SMALL BORE NASOENTERIC
protect the urine from light during
• Small-bore nasoenteric (eg, collection. The powder helps preserve
nasoduodenal, nasojejunal) tubes are often the urine and adjusts its acidity
placed using a stylet (guide wire), a metal o Collection of the 24-hour urine should
wire running through the tube that facilitates span over exactly 24 hours. It is
advancement through the gastrointestinal important to first record the time and
tract. empty the bladder into the toilet so that
the start time coincides with an empty
• Once the tube is inserted, the nurse should bladder. At that exact time the next
obtain an x-ray to verify that the tube day, the bladder should be emptied for
terminates in the intestine as prescribed, a final time and collected into the
not in the airway or stomach. jug. All urine between the start time
• After placement verification, the nurse and end time should be collected into
should remove the stylet to allow tube the container. The time for each
feeding urination between start and end does
not need to be recorded
• To avoid perforating the gut, the nurse o Keep the urine in a refrigerator or a
should never reinsert the stylet when a cooled ice chest with the lid tightly
feeding tube is in place. If the tube is not screwed on for preservation
properly positioned and the stylet has been
removed, the nurse must remove the tube CLIENT POSITIONING
and start over.
• For medical procedures, the nurse should
• The client should sip water during insertion
ensure that the client:
to close the airway and open the
esophagus. With each swallow the nurse
o Has an empty bladder and is in high
should advance the tube a little. The nurse
Fowler's or a sitting position for
should stop advancing when the client is
paracentesis
inhaling or coughing to avoid inserting the
o Is Trendelenburg on the left side for
tube into the airway and then continue
suspected air embolism
advancing when the client is able to
o Has the arm raised above the head on
swallow again.
the affected side for chest tube
• Marking the exit point from the naris on the insertion
tube allows visualization of changes in o Lies on the right side (for 2 hours) and
external tube length that may indicate tube then supine (12-14 hours) after liver
dislodgement. biopsy
o Is side-lying with the head, back, and
knees flexed for lumbar puncture
ETT SUCTIONING o Elevate the head of the bed ≥30
degrees and keep it elevated for at
• Clients with endotracheal tubes least 30 minutes after feeding to
(ETTs) have impaired cough and gag minimize the risk of aspiration
reflexes and require suction to clear o Validate tube placement by checking
retained bronchial secretions and the gastric pH as well as assessing the
promote ventilatory efficacy. Ventilator external tube length and comparing it
circuits for ETTs typically have a reusable with the measurement at the time of
in-line endotracheal suction device, which insertion. The tube should be marked
remains sterile, in a flexible plastic at the nostril with a permanent marker
sleeve. Oral secretions may pool near the during the initial x-ray validation
base of the ETT and drip into the trachea; o Check gastric residual volume.
therefore, oropharyngeal suctioning and o Flush the tube with 30 mL of
oral care are performed before ETT water after checking residual volume,
suctioning to prevent introduction of oral every 4-6 hours during feeding, and
bacteria into the lungs. before and after medication
• The steps for suctioning an ETT include: administration
o Administer the prescribed enteral
1. Perform hand hygiene and don clean feeding solution by connecting the
gloves tubing and setting the rate on the
2. Suction the oropharynx and perform infusion pump
oral care
3. Ensure that the system is connected to
appropriate wall suction (<120 mm Hg).
4. Hyperoxygenate the lungs (100% SPUTUM C/S TESTING
FiO2)
5. Advance the catheter into the trachea • Sputum culture and sensitivity testing is
just until resistance is met (level of the used to identify infectious organisms in the
carina). Do not suction while respiratory tract and determine which
advancing the catheter. antimicrobials are most effective at treating
6. Gently remove the catheter while the identified organism. Nurses assisting a
suctioning and rotating it. Do not client to collect sputum should instruct the
suction for more than 10 seconds client to:
7. Evaluate client tolerance; if further
o Rinse the mouth with water before
secretions remain, suctioning can be
collecting the sputum sample to reduce
repeated 1 or 2 times. Document the
bacteria in the mouth and prevent
procedure when complete
specimen contamination by oral flora
8. Resume oxygenation and ventilation
settings as prescribed. o Avoid touching the inside of the sterile
container or lid to avoid accidental
CONTINUOUS ENTERAL FEEDING specimen contamination by normal flora
of the skin
• The steps for administering a continuous
o Inhale deeply several times and
enteral feeding include:
then cough forcefully, which promotes
expectoration of lower lung secretions
o Identify the client using 2
and increases sample volume
identifiers (eg, first and last name,
medical record number, date of o Assume a sitting or upright position
birth) and explain the procedure to the before specimen collection, if possible,
client. Perform hand hygiene and apply to promote cough strength during
clean gloves. collection
• Sputum specimens should be collected 1. Perform hand hygiene, and apply
early in the morning after awakening, which clean gloves. Remove the old
improves the quality of the sample because dressing. Remove and discard
secretions accumulate overnight due to gloves.
cough inhibition. A nebulizer treatment may 2. Perform hand hygiene, and
be prescribed to help mobilize thick apply sterile gloves. Assess the
secretions. wound bed. Cleanse the wound bed
and surrounding skin with normal
PERIPHERALLY INSERTED CENTRAL saline (eg, flushing, swabbing with
VENOUS CATHETERS (PICC) gauze) to remove drainage and
• Peripherally inserted central venous debris. Remove and discard gloves.
catheters (PICC) are commonly used for 3. Perform hand hygiene, and
long-term antibiotic administration, apply clean gloves. Gently swab
chemotherapy treatments, and nutritional the wound bed with a
support with total parenteral nutrition sterile swab, from the wound
(TPN). center toward the outer margin.
• Complications related to the PICC are Avoid contact with skin at the
occlusion of the catheter, phlebitis, air wound edge as it can contaminate
embolism, and infection due to bacterial the specimen with skin flora.
contamination. 4. Place the swab in a sterile specimen
• Prior to a central line dressing change, the container; avoid touching the swab to
nurse performs hand hygiene. The central the outside of the container.
line dressing change is performed 5. Apply prescribed topical medication
using sterile technique with the nurse (eg, bacitracin) after obtaining
wearing a mask to prevent contamination of cultures to prevent interference with
the site with microorganisms or respiratory microorganism identification. Apply
secretions new dressing.
• During injection cap and tubing changes, 6. Remove and discard gloves, and
the client is instructed to hold the perform hand hygiene. Label the
breath (or perform the Valsalva maneuver) specimen, and document the
to prevent air from entering the line, procedure.
traveling to the heart, and forming an air
embolism BLOOD ADMINISTRATION TUBING
• When performing the dressing change,
the client should be instructed to turn the • Normal saline (NS) is the only fluid that
head away from the PICC site to prevent can be given with a blood transfusion.
potential contamination of the insertion site • Dextrose solutions may lyse the red blood
by microorganisms from the client's cells. All other IV solutions and
respiratory tract. medications may cause precipitation and
• During dressing, injection caps, and tubing are incompatible with blood.
changes, the client is placed in the supine
position. If an air embolism is suspected, • Blood transfusions should be infused
the client should be placed in the through a dedicated IV line. If a
Trendelenburg position (head down) on the transfusion must be started in an IV
left side, causing any existing air to rise and catheter currently in use, the nurse should
become trapped in the right atrium. discontinue the infusion(s) and tubing, and
then flush the catheter with NS prior to
WOUND CULTURE connecting the blood administration tubing.
• Wound cultures identify microorganisms to • After transfusion, the catheter should be
aid in prescribing appropriate antibiotics cleared with NS before any other IV fluids
and are obtained as follows: are administered.
• Packed red blood cells are not compatible prevent mucosal tissue damage and
with D5W. The nurse must discontinue the limit hypoxia.
D5W and flush the catheter with NS before
administering blood. OPEN ENDOTRACHEAL SUCTIONING
• Although an 18-gauge IV catheter is
• Open endotracheal (ET) suctioning is a
preferred for blood administration, a 20- skill performed to remove pulmonary
gauge catheter is acceptable. The nurse secretions and maintain airway patency in
can start a second IV catheter if required, clients who are unable to clear secretions
but there is no need to discontinue the independently. ET suctioning is important
original one. to promote gas exchange and prevent
• Blood should not be run with any other fluid alveolar collapse, but inappropriate
except NS. Blood can be infused with an IV technique increases the client's risk for
pump if the fluid in the tubing is compatible. complications (eg, pneumonia, hypoxemia)
or tracheal injury (eg, trauma, bleeding). To
reduce the risk of complications and injury
TRACHEOSTOMY TUBE SUCTIONING during ET suctioning, the nurse should:

• When performing the suctioning procedure, o Preoxygenate with 100% oxygen and
the nurse follows institution policy and allow for reoxygenation periods
observes principles of infection control and between suction passes
client safety. Strict aseptic technique is o Suction only while withdrawing the
maintained because suctioning can catheter from the airway
introduce bacteria into the lower airway and
lungs. o Use strict sterile technique throughout
suctioning
1. Place the client in semi-Fowler's o Limit suctioning to ≤10 seconds on
position, if not contraindicated, to each suction pass
promote lung expansion and
oxygenation. IFC REMOVAL
2. Preoxygenate with 100% oxygen • Because signs of traumatic injury are
(hyper-oxygenate) to prevent hypoxemia
present, the nurse should follow steps
and microatelectasis. Alternately, if the
to remove the catheter before further
client is breathing room air complications such as obstruction occur.
independently, ask the client to take 3-4
• Steps for removing an indwelling catheter
deep breaths.
include the following:
3. Insert the catheter gently the length of
the airway without applying suction to
o Perform hand hygiene
prevent mucosal tissue damage. The
o Ensure privacy and explain the
distance can be premeasured (0.4-0.8 in
procedure to the client
[1-2 cm] past the distal end of the tube).
o Apply clean gloves
4. Withdraw the catheter slightly (0.4-0.8
o Place a waterproof pad underneath the
in [1-2 cm]) if resistance is felt at the
client
carina (bifurcation of the left and right
o Remove any adhesive tape or device
mainstem) to prevent mucosal tissue
anchoring the catheter
damage.
o Follow specific manufacturer
5. Apply intermittent suction while
instructions for balloon deflation
rotating the suction catheter during
o Loosen the syringe plunger and
withdrawal to prevent mucosal tissue
connect the empty syringe hub into the
damage. Limit suction time to 5-10
inflation port
seconds with each suction pass to
 o Deflate the balloon by allowing water site. The liver is a "heavy" organ and can
to flow back into the syringe naturally, "fall on itself" to tamponade any
removing all 10 mL, or applicable bleeding. The client stays on bed rest for
amount (note the size of the balloon 12-14 hours.
labeled on the balloon port). If water
does not flow back naturally, use only
gentle aspiration. KCL IV INFUSION
o Remove the catheter gently and
slowly; inspect to make sure it is intact • The recommended rates for an intermittent
and fragments were not left in the IV infusion of potassium chloride (KCl)
client. are no greater than 10 mEq (10 mmol)
o If any resistance is met, stop the over 1 hour when infused through
removal procedure and consult with the a peripheral line and no greater than 40
urologist for removal mEq/hr (40 mmol/hr) when infused through
o Empty and measure urine before a central line (follow facility guidelines and
discarding the catheter and drainage policy).
bag in the biohazard bin or according to • If the nurse were to administer the
hospital policy medication as prescribed, the rate would
o Remove gloves and perform hand exceed the recommended rate of 10
hygiene mEq/hr (10 mmol/hr) (ie, 10 mEq [10 mmol]
over 30 minutes = 20 mEq/hr [20
LIVER BIOPSY mmol/hr]).
• A too rapid infusion can lead to pain and
• The client's coagulation status is checked irritation of the vein and postinfusion
before the liver biopsy using PT/INR and phlebitis.
PTT. • Contacting the health care provider to verify
this prescription is the priority action.
• The liver ordinarily produces many
coagulation factors and is a highly vascular IV INSERTION
organ. Therefore, bleeding risk should be • Steps to promote safety and reduce
assessed and corrected prior to the biopsy infection risk when initiating IV
• Blood should be typed and crossmatched in therapy include the following:
case hemorrhage occurs
1. Perform hand hygiene using Centers
• After the procedure, frequent vital sign for Disease Control and Prevention
monitoring is indicated as the early signs of guidelines
hemorrhage are rising pulse and 2. Prepare equipment: Open IV tray,
respirations, with hypotension occurring prime tubing with prescribed IV solution
later for infusion, set IV pump if indicated,
prepare tape, and open the over-the-
• The needle is inserted between ribs 6 and 7
needle catheter (ONC) with safety
or 8 and 9 while the client lies supine with
device
the right arm over the head and holding
3. Don clean (non-sterile) gloves
the breath. 4. Identify a possible venipuncture site
• A full bladder is a concern with 5. Apply a tourniquet, ensuring it is tight
paracentesis when a trocar needle is enough to impede venous return but not
inserted into the abdomen to drain tight enough to occlude the artery
ascites. An empty bladder may aid comfort, 6. Select a venipuncture site after
but it is not essential for safety. palpating the vein. Ask the client to
open and close the hand several times
• The client must lie on the right side for a to promote vein distension. The
minimum of 2-4 hours to splint the incision tourniquet may need to be released
 temporarily to restore blood flow and hypoxemia, trauma, infection), suctioning
prevent trauma from extended should be performed only when necessary.
application. • Assessment findings that indicate a need
7. Clean the site with chlorhexidine, for suctioning include:
alcohol, or povidone iodine. Use friction
and clean per facility protocol, either o Decreased oxygen saturation
back and forth or in a circular motion o Altered mental status (eg, irritability,
from insertion site to outward area lethargy)
(clean to dirty direction). o Increased heart rate (normal infant
8. Stretch the skin taut using the range: 90-160)
nondominant hand to stabilize the vein o Increased respiratory rate (normal
9. Insert the IV ONC bevel up at a 10- to infant range: 30-60)
30-degree angle and watch for blood o Increased work of breathing (eg, flared
backflow as the catheter enters the vein nostrils, use of accessory muscles)
lumen, advancing ¼ inch into the vein to o Adventitious breath sounds (eg,
release the stylet. On visualization of crackles, wheezes, rhonchi)
blood return, lower the ONC almost o Pallor, mottled, or cyanotic skin coloring
parallel with the skin and thread the
plastic cannula completely into the vein PERCUTANEOUS KIDNEY BIOPSY
to the insertion site. Never reinsert the
stylet after it is loosened. Use the push- • Percutaneous kidney biopsy is an invasive
tab safety device to advance the diagnostic procedure. It involves inserting a
catheter. needle through the skin to obtain a tissue
10. Apply firm but gentle pressure about 1¼ sample that is then used to determine the
inch above the catheter tip, release the cause of certain kidney diseases.
tourniquet, and retract the stylet from
the ONC • The kidney is a highly vascular organ;
11. On removal, guide the protective guard therefore, uncontrolled hypertension is
over the stylet for safety and feel for a a contraindication for kidney biopsy as
click as the device is locked. Never try increased renal arterial pressure places the
to recap a stylet. client at risk for post-procedure bleeding.
12. Attach a sterile connection of primed IV • Blood pressure must be lowered and well-
tubing to the hub of the catheter and controlled (goal <140/90 mm Hg) using
stabilize the catheter with tape and antihypertensive medications before
dressing using sterile performing a kidney biopsy
technique. Dispose of the stylet in the
sharps container. • An elevated serum creatinine level (normal:
0.6-1.3 mg/dL [53-115 µmol/L) can be
expected in a client with probable renal
disease. This is not the most important
SUCTIONING finding to report to the HCP.
• A decreased hemoglobin level (normal
• Artificial airways (eg, tracheostomies,
adult male: 13.2-17.3 g/dL [132-173 g/L];
endotracheal tubes) impair the
normal adult female: 11.7-15.5 g/dL [117-
cough mechanism and ciliary function,
155 g/L]) can be expected in a client with
causing an increase in thick
probable renal disease due to decreased
secretions that may occlude the
erythropoietin production. The nurse
airway. Focused respiratory assessments
should continue to monitor the client's
are critical to determine the need for
hemoglobin post-procedure as it can
suctioning and to maintain a patent
decrease further (within 6 hours) if bleeding
airway. To decrease the risks associated
occurs.
with the procedure (eg, atelectasis,
• Only neurosurgery and ocular surgery progresses from no touch down, non-weight
require a platelet count >100,000/mm3 (100 bearing status, using the 3-point gait to
x 109/L). Most other surgeries can be touch down with partial weight bearing
performed when the platelet count is status, using the 2 point-gait, to full weight
>50,000/mm3 (50 x 109/L). Although the bearing status, using the 4-point gait.
platelet count is low (normal 150,000-
• The nurse teaches the client how to use
400,000/mm3 [150-400 x109/L]), it is not the
the most advanced gait, the 4-point crutch
most important finding to report to the HCP.
gait. It requires weight bearing on both
legs and is the most stable as there are 3
points of support on the ground at all times
IV CATHETER SIZE
(eg, 2 crutches and 1 foot; 2 feet and 1
• When selecting catheter size, the need for crutch). It is the easiest to use as
rapid fluid administration and the type of it resembles normal walking: advance
fluid administered versus client discomfort right crutch, then left foot, and advance left
should be assessed. A lower IV catheter crutch, then right foot.
gauge number corresponds to a larger bore
• There are 5 crutch gaits: 2-point, 3-point, 4-
IV catheter.
point, swing-to, and swing-through. There
is no 5-point crutch gait.
1. A 14-gauge (large-bore) catheter may
be used for administering fluids and
drugs in an emergency or prehospital
setting, or for hypovolemic shock
2. In somewhat stable adult clients who
require large amounts of fluids
or blood, an 18-gauge catheter is
preferred.

• A 20-22-gauge catheter is sufficient for

administering general IV fluids and
medications to adult clients; a 20-gauge is
acceptable for blood transfusion. However,
20-22-gauge is not preferred for blood
administration.
• A 24-gauge catheter is recommended for
children and some older adults with small,
fragile veins.

4-POINT CRUTCH GAIT

TST (MANTOUX TEST)

• TST (Mantoux) is the standard method for
conducting tuberculosis (TB) surveillance of
HCWs and involves 2 steps:
• The client who is rehabilitating from an
injury of the lower extremity usually
 1. Injection of purified protein derivative reaction; these may include
solution under the first layer of skin of vasopressors, antihistamines, steroids,
the forearm or IV fluids
2. Evaluation of the injection site 48-72 o Collect a urine specimen to be
hours later assessed for a hemolytic reaction
o Document the occurrence and send the
• The health care practitioner inspects and remaining blood and tubing set back to
palpates the site to determine if a local skin the blood bank for analysis
reaction has occurred.
• Induration (not redness) indicates a positive
test, which means that the individual has
been exposed to TB, has developed
antibodies, and is infected with TB
bacteria.
• Further testing is needed to determine the
presence of latent TB infection or active TB
disease.
• Presence of symptoms, positive sputum
culture, and chest x-ray abnormalities
confirm active TB.
• The QuantiFERON-TB (QFT) blood test is
an alternative to TST that measures how
the immune system reacts to TB bacteria.
• Like TST, a positive QFT test only indicates
that the individual has been infected with
TB bacteria. Although the test is more
expensive, it requires only a single visit to
the health care provider and results are
available in 24 hours.

TRANSFUSION REACTION
• It is important for the nurse to remain with
the client for 15 minutes after starting a
blood transfusion to monitor for signs of a
reaction. These signs include fever, chills,
nausea, vomiting, pruritus, hypotension,
decreased urine output, back pain, and
dyspnea. The client may report a variety of
symptoms ranging from none to a feeling of
impending doom. If signs of a transfusion
reaction occur, the nurse should:

o Stop the transfusion immediately

o Using new tubing, infuse normal saline
to keep the vein open
o Continue to monitor hemodynamic
status and notify the health care
provider and blood bank.
o Administer any emergency
or prescribed medications to treat the