Nursing Skills and Procedures

Nursing skills and procedures are the structured psychomotor interventions nurses perform to assess, treat, and protect patients. Competent performance requires more than memorized steps. It requires knowing why each step exists, what assessment must occur before and after, which findings stop the procedure, and who must be notified. This article covers the core skill set tested on both the NCLEX-RN and the NCLEX-PN.

Principles That Apply to Every Procedure

Before any skill, the nurse verifies the order, identifies the patient using two identifiers, performs hand hygiene, explains the procedure and obtains consent or cooperation, provides privacy, gathers supplies, and positions the patient. After any skill, the nurse assesses the patient's response, restores safety measures such as bed in low position and call light in reach, performs hand hygiene, and documents what was done, what was found, how the patient tolerated it, and what was reported.

Clean versus sterile technique

Medical asepsis, also called clean technique, reduces the number of microorganisms and is used for routine hygiene, most chronic wound care, and administration of oral medications. Surgical asepsis, or sterile technique, eliminates microorganisms and is required whenever a body cavity or the bloodstream is entered or a break in skin integrity is dressed in an acute care setting. Sterile technique is required for urinary catheter insertion, tracheal suctioning, intravenous insertion, central line dressing changes, and most acute surgical wound dressing changes.

Sterile field rules worth memorizing because they generate exam items:

• A one inch border around the sterile field is considered contaminated.
• Anything below waist level or out of the line of vision is contaminated.
• Moisture wicks microorganisms, so a wet field is a contaminated field.
• Reaching across a sterile field contaminates it. Move around the field instead.
• Sterile items are held above waist level and in front of the body.
• The nurse never turns away from the field.

Standard and transmission-based precautions

Standard precautions apply to all patients regardless of diagnosis. Transmission-based precautions are added by route.

• Contact precautions: gown and gloves. Used for Clostridioides difficile, multidrug resistant organisms, scabies, draining wounds, and respiratory syncytial virus. C. difficile additionally requires soap and water handwashing, because alcohol-based rub does not kill spores, and a bleach-based sporicidal cleaner.
• Droplet precautions: surgical mask within about three to six feet. Used for influenza, pertussis, Neisseria meningitidis, mumps, and rubella. Private room preferred.
• Airborne precautions: negative pressure room and a fit-tested N95 or higher respirator. Used for tuberculosis, measles, and varicella. Varicella and disseminated zoster require both airborne and contact precautions.

Delegation and scope

Assistive personnel may perform standardized tasks with predictable outcomes on stable patients, such as vital signs, hygiene, ambulation, feeding a patient without swallowing risk, emptying a drainage bag and reporting the volume, and specimen collection from a voided sample. Assistive personnel do not assess, teach, evaluate, or perform sterile procedures. Licensed practical and vocational nurses perform most established skills, administer most routine medications, and reinforce teaching the registered nurse initiated. The registered nurse retains initial assessment, care planning, initial teaching, evaluation of outcomes, and care of the unstable patient, and in most jurisdictions retains intravenous push medications, blood product administration, and central line management. State nurse practice acts vary, and exam answers follow the most restrictive common standard.

Wound Care and Dressing Changes

Wound classification and healing

Wounds heal by primary intention when edges are approximated, as in a clean surgical incision, by secondary intention when the wound is left open to granulate, as in a pressure injury or dehisced wound, and by tertiary or delayed primary intention when a contaminated wound is left open then closed later. Phases of healing are hemostasis, inflammation, proliferation, and maturation or remodeling. Inflammation in the first several days produces warmth, erythema, edema, and serosanguineous drainage, which is expected and is not automatically infection.

Drainage terminology:

• Serous: clear, thin, watery. Expected.
• Sanguineous: bright red, fresh bleeding.
• Serosanguineous: pink and watery. Common in the first 48 hours.
• Purulent: thick, opaque, yellow, green, tan, or brown. Suggests infection.

Pressure injury staging

• Stage 1: intact skin with nonblanchable erythema. In darker skin tones look for a color change compared with surrounding skin plus warmth, firmness, or boggy texture.
• Stage 2: partial thickness loss of dermis, shallow, pink or red moist wound bed, or an intact or ruptured serum-filled blister. No slough, no granulation, no adipose visible.
• Stage 3: full thickness loss with visible adipose tissue. Slough or eschar may be present but does not obscure the depth. Undermining and tunneling may occur. Bone, tendon, and muscle are not exposed.
• Stage 4: full thickness loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone.
• Unstageable: base obscured by slough or eschar so depth cannot be determined.
• Deep tissue pressure injury: persistent nonblanchable deep red, maroon, or purple discoloration, or a blood-filled blister, over intact or nonintact skin.

Application note: stable, dry, adherent eschar on an ischemic heel is not debrided. It acts as a biological cover. The nurse protects it, offloads the heel, and reports changes such as new erythema, fluctuance, drainage, or odor.

Dressing types and matching

• Gauze: inexpensive, useful for packing, requires frequent change, does not maintain moisture well.
• Transparent film such as Tegaderm: for stage 1 injuries, superficial wounds, and intravenous sites. Allows visualization and gas exchange. Not absorbent, so do not use on heavily draining wounds.
• Hydrocolloid such as DuoDERM: occlusive, keeps the wound moist, promotes autolytic debridement, used on clean stage 2 and shallow stage 3 wounds. Produces a normal odorous gel that students often mistake for infection. Not for infected wounds.
• Hydrogel: donates moisture to dry wounds, soothing, used on dry sloughy or painful wounds.
• Alginate: highly absorbent, derived from seaweed, for heavily exudating wounds, requires a secondary cover dressing.
• Foam: absorbent and cushioning, common for moderate exudate and for prophylactic sacral protection.

The governing principle is moisture balance: keep the wound bed moist and the surrounding intact skin dry. Wet-to-dry gauze performs nonselective mechanical debridement, damages new granulation tissue, and is painful. It is no longer recommended as routine care and should be questioned when ordered for a clean granulating wound.

Negative pressure wound therapy

Negative pressure wound therapy applies subatmospheric pressure through a sealed foam dressing to remove exudate, reduce edema, and promote granulation. The nurse ensures an airtight seal, monitors canister output and character, and reports a lost seal or an alarm. It is contraindicated over untreated osteomyelitis, malignancy in the wound, exposed vessels, organs, or anastomoses, and necrotic tissue with eschar. Active bleeding into the canister is an emergency.

Step sequence for a sterile dressing change

1. Verify the order, assess pain, and premedicate so the analgesic peaks during the change.
2. Perform hand hygiene, don clean gloves, and remove the old dressing, moistening it with sterile saline if it adheres so granulation tissue is not stripped.
3. Assess the old dressing for amount, color, odor, and consistency of drainage, then discard it and the gloves and perform hand hygiene again.
4. Set up the sterile field, open supplies onto it, and pour solution without reaching across the field.
5. Don sterile gloves. Assess the wound bed, measure length, width, and depth, and probe for undermining and tunneling using clock terminology with 12 o'clock toward the patient's head.
6. Clean from least contaminated to most contaminated, moving from the incision outward, using a new gauze for each stroke. Never return a used gauze to the wound.
7. Pack loosely if ordered. Overpacking raises pressure and impairs perfusion. Packing is counted in and counted out and documented.
8. Apply the new dressing, secure it, and label it with date, time, and initials.
9. Reassess the patient and document findings and tolerance.

Complications

Dehiscence is separation of the wound layers. Evisceration is protrusion of viscera through the opening. If evisceration occurs, the nurse stays with the patient, positions low Fowler with knees bent to reduce abdominal tension, covers the organs with sterile gauze moistened with sterile normal saline, does not attempt to reinsert anything, keeps the patient NPO, monitors for shock, and notifies the surgeon immediately. Infection is suggested by purulent drainage, increasing pain after the third postoperative day, fever, erythema spreading beyond the incision, and leukocytosis. A wound culture is obtained from viable tissue in the wound bed after cleansing with normal saline, not from exudate or eschar, and before antibiotics are started when possible.

Urinary Catheterization

Indications and anatomy

A straight or intermittent catheter drains the bladder once, obtains a sterile specimen, or measures residual urine. An indwelling Foley catheter provides continuous drainage for acute urinary retention, bladder outlet obstruction, accurate output measurement in critical illness, perioperative need, and comfort in end of life care. Indwelling catheters are not appropriate for incontinence alone or for staff convenience, because every catheter day increases catheter-associated urinary tract infection risk. A condom or external catheter is the safer alternative for male incontinence, and external female pouch devices exist as well.

The female urethra is about 3 to 4 cm long. The male urethra is about 18 to 20 cm and curves, which is why the penis is held perpendicular to the body with gentle traction during insertion.

Insertion sequence

1. Explain the procedure, provide privacy, and position: female dorsal recumbent with knees flexed, male supine with legs slightly apart.
2. Perform hand hygiene, set up the sterile field, and don sterile gloves. Test the balloon only if manufacturer instructions direct it, since repeated testing can create creases.
3. Lubricate the catheter generously. Men benefit from instilled lidocaine lubricant when policy allows.
4. Clean with the nondominant hand, which is now contaminated and does not leave the field. For the female patient, separate the labia and maintain that separation until the catheter is in, cleaning front to back from the far labium, then the near labium, then the meatus, using a new swab each stroke. For the male patient, retract the foreskin if uncircumcised and clean in a circular motion from the meatus outward.
5. Insert with the sterile dominant hand: about 5 to 7.5 cm, roughly 2 to 3 inches, in the female patient and about 17 to 22.5 cm, roughly 7 to 9 inches, in the male patient, or until urine returns.
6. When urine returns, advance an additional 2.5 to 5 cm in the female patient, or to the bifurcation of the catheter in the male patient, before inflating the balloon. Never inflate a balloon before urine return, because inflating in the urethra causes trauma and can rupture the urethra.
7. Inflate the balloon with the prefilled sterile water syringe using the full stated volume. Never use saline, which can crystallize.
8. Gently pull back until resistance is felt, secure the tubing to the thigh or abdomen with a securement device to prevent traction, and reduce the foreskin in the uncircumcised male patient. Failing to reduce the foreskin can cause paraphimosis.
9. Hang the bag below bladder level, off the floor, and keep the tubing free of dependent loops.

If resistance is met, the nurse stops, does not force, and notifies the provider. Forcing risks urethral false passage. If the catheter is contaminated during insertion, it is discarded and a new sterile catheter is used.

Maintenance and complications

Keep the closed drainage system intact. Perform perineal care with soap and water daily and after bowel movements. Do not routinely irrigate. Ensure adequate fluid intake unless contraindicated. Clamp the tubing briefly and withdraw specimens only from the needleless sampling port after disinfecting it, never from the collection bag and never by disconnecting the tubing.

Traditional teaching, still reflected on many licensure exams, is to drain no more than roughly 750 to 1000 mL at one time in a chronically distended bladder to reduce the risk of hypotension and mucosal hemorrhage. Contemporary evidence suggests rapid complete drainage is usually well tolerated. Follow facility policy, monitor blood pressure, and know the classic exam answer.

Absent urine output after insertion is assessed before it is escalated: check for kinks, dependent loops, bag position, and constipation, and confirm the catheter is in the bladder and not the vagina. Bladder scanning determines whether the bladder actually holds urine. Suprapubic distension with no output in a patient with an intact catheter suggests obstruction and requires notification.

Autonomic dysreflexia is a life-threatening emergency in patients with spinal cord injury at or above T6, most often triggered by a distended bladder or bowel. Presentation is sudden severe hypertension, pounding headache, bradycardia, flushing and sweating above the level of injury, and pallor below it. The nurse raises the head of the bed immediately, then removes the trigger, most often by relieving the obstructed catheter, and notifies the provider.

Specimen Collection

General rules: label at the bedside in the presence of the patient, use the correct container and preservative, avoid contaminating the inside of the lid, transport promptly, and document collection time. Cultures are ideally obtained before the first dose of antibiotics.

• Clean catch midstream urine: cleanse the meatus front to back with the provided wipes, begin voiding into the toilet, then catch the midstream portion without stopping the stream. This flushes urethral flora.
• Sterile urine from an indwelling catheter: clamp the tubing distal to the port for about 15 to 30 minutes, disinfect the port, withdraw with a sterile syringe, and unclamp. Never collect from the drainage bag, which contains stagnant colonized urine.
• 24 hour urine: discard the first void and start timing at that moment, collect every void for 24 hours, keep the specimen chilled or on ice as required, and include the final void at the end of the period. A discarded void invalidates the collection and it starts over.
• Sputum: best obtained early in the morning before eating, after rinsing the mouth with plain water, never mouthwash, which is antimicrobial. Instruct the patient to take several deep breaths and cough deeply from the lungs. Saliva is not a specimen. For acid-fast bacilli, serial early morning specimens on separate days are typical.
• Stool for ova and parasites: no barium, mineral oil, laxatives, or antacids for the preceding period specified by the laboratory, and the specimen must not be contaminated with urine or toilet water. Warm stool for parasites goes to the laboratory promptly.
• Stool for occult blood: avoid red meat, and depending on the test, certain medications such as nonsteroidal anti-inflammatory drugs and anticoagulants, and high-dose vitamin C, which can cause false results.
• Blood cultures: two sets from two separate sites, obtained before antibiotics, using rigorous skin antisepsis with chlorhexidine allowed to dry. Fill the aerobic and anaerobic bottles per policy.
• Wound culture: cleanse with normal saline first, then swab viable tissue in the wound bed using a rotating motion. Do not swab pus, slough, or eschar.
• Throat culture: swab the tonsillar pillars and posterior pharynx, avoid the tongue and uvula, and be prepared for gagging.

Enteral Nutrition and Tube Feeding

Tube types

Nasogastric and orogastric tubes are short-term, generally under four to six weeks. Gastrostomy and jejunostomy tubes are surgically or endoscopically placed for long-term feeding. Small-bore feeding tubes are more comfortable but collapse with aspiration and clog easily. Large-bore sump tubes such as the Salem sump are used for decompression, and the blue air vent, the pigtail, is kept above the level of the stomach and is never clamped or used for irrigation.

Verifying placement

Radiographic confirmation is the gold standard after initial blind insertion and before the first use of a small-bore tube. Before each feeding or medication administration thereafter, the nurse aspirates gastric contents and checks pH. A pH of about 5.5 or lower supports gastric placement, although acid-suppressing medications raise gastric pH and reduce the reliability of this test. The nurse also measures the external tube length and compares it with the documented insertion mark. Auscultation of an air bolus over the epigastrium, the "whoosh" test, is not reliable and is not acceptable practice. Any new coughing, choking, voice change, or falling oxygen saturation demands that feeding stop and placement be reverified.

Administration

• Head of bed elevated 30 to 45 degrees during feeding and for at least 30 to 60 minutes afterward, unless contraindicated. This is the single most important aspiration precaution.
• Check gastric residual volume per policy. Traditional thresholds hold feeding for a residual above 500 mL and prompt closer assessment between about 200 and 500 mL. Current critical care guidance discourages routine residual checks as the sole marker of tolerance; assess for distension, nausea, vomiting, and bowel sounds as well. Return aspirated contents per facility policy to avoid electrolyte and acid loss.
• Flush with about 30 mL of water before and after feeding and medications and every four to six hours during continuous feeding, and use warm water, not cola or juice, to relieve or prevent clogging.
• Formula hangs no longer than the manufacturer's stated time, commonly four to eight hours for open systems, and the container and tubing are changed per policy.
• Give medications one at a time in liquid form when available, flushing between each. Do not crush enteric-coated, sustained-release, or extended-release forms, and do not add medications directly to the formula bag.
• Hold enteral feeding for one to two hours before and after phenytoin, because the formula markedly reduces its absorption.

Complications

Diarrhea is the most common complication and prompts evaluation of formula osmolarity, rate, sorbitol-containing medications, and infection rather than immediate discontinuation. Dumping syndrome, seen especially with jejunal feeding and hyperosmolar formula, produces cramping, diaphoresis, tachycardia, and diarrhea shortly after feeding. Refeeding syndrome occurs when nutrition is restarted in a severely malnourished patient and produces a dangerous drop in phosphate, magnesium, and potassium with cardiac and respiratory failure; start slowly and monitor electrolytes. Aspiration is the most dangerous complication: stop the feeding immediately, turn the patient to the side, suction, provide oxygen, assess breath sounds and saturation, and notify the provider.

Oxygen Administration Devices

Oxygen is a drug and requires an order, including device, flow rate, and target saturation. Humidification is generally added above about 4 L/min to prevent mucosal drying and epistaxis. Safety measures include no smoking, no petroleum-based products near the face, no open flame, avoidance of static-generating synthetic fabrics, secured cylinders, and functioning fire safety equipment.

Device	Typical flow	Approximate FiO2	Key points
Nasal cannula	1 to 6 L/min	about 24 to 44 percent	Comfortable, allows eating and talking. Assess nares and ears for pressure injury.
Simple face mask	5 to 10 L/min	about 40 to 60 percent	Minimum of 5 L/min is required to flush exhaled carbon dioxide from the mask.
Partial rebreather	6 to 11 L/min	about 60 to 75 percent	Reservoir bag must not fully collapse on inspiration.
Nonrebreather	10 to 15 L/min	about 80 to 95 percent	One-way valves; keep the reservoir bag inflated. Used for acute severe hypoxemia.
Venturi mask	per color-coded adapter	24 to 60 percent, precise	The most accurate delivery. Preferred when a precise low concentration is needed, as in chronic obstructive pulmonary disease.
High-flow nasal cannula	up to 60 L/min	up to about 100 percent	Heated and humidified, provides some positive pressure, tolerated better than a mask.

Application notes: in a patient with chronic obstructive pulmonary disease, the nurse does not withhold oxygen from a hypoxemic patient, but titrates to a target saturation commonly around 88 to 92 percent and monitors for rising carbon dioxide with decreasing level of consciousness. Deteriorating mental status in a patient receiving oxygen is a respiratory emergency, not a sedation issue. If a nonrebreather reservoir bag is collapsing, the nurse increases the flow rate.

Related airway skills

For tracheostomy care, the nurse uses sterile technique, keeps a spare tube of the same size and one size smaller plus an obturator at the bedside, secures new ties before removing old ties, and holds the tube during tie changes. If the tube becomes dislodged, the nurse retracts the stoma with a curved hemostat and attempts reinsertion using the obturator; if the airway cannot be reestablished, the nurse covers the stoma and ventilates with a bag-mask over the mouth and nose while calling for help. Suctioning is applied only on withdrawal, for no more than about 10 to 15 seconds per pass, with hyperoxygenation before and after, and the patient is never suctioned routinely on a schedule but rather when adventitious sounds, secretions, or desaturation indicate need. Saline instillation before suctioning is not recommended.

Injections

Route comparison

Route	Angle	Needle	Usual volume	Sites
Intradermal	5 to 15 degrees, bevel up	26 to 27 gauge, 3/8 to 5/8 inch	0.01 to 0.1 mL	Inner forearm, upper back
Subcutaneous	45 to 90 degrees	25 to 27 gauge, 3/8 to 5/8 inch	up to about 1 mL	Abdomen, posterior upper arm, anterior thigh, upper back
Intramuscular	90 degrees	20 to 25 gauge, 1 to 1.5 inch	up to 3 mL in a large adult muscle	Ventrogluteal, deltoid, vastus lateralis

Intradermal

Used for tuberculin skin testing and allergy testing. The needle is inserted bevel up at a shallow angle until the bevel is just covered, and a 6 to 10 mm wheal should form. The site is not massaged. A tuberculin test is read at 48 to 72 hours by palpating and measuring induration, not erythema. Interpretation thresholds are 5 mm in the immunosuppressed and close contacts of active cases, 10 mm in higher-risk groups such as recent immigrants, injection drug users, and health care workers, and 15 mm in people with no known risk factors. A positive skin test indicates exposure, not active disease, and is followed by chest imaging and symptom assessment.

Subcutaneous

Angle is chosen by tissue depth: 90 degrees when at least 2.5 cm, or one inch, of tissue can be grasped, and 45 degrees when only about 1.25 cm can be grasped. Aspiration is not performed for subcutaneous injections.

• Heparin: give in the abdomen at least 5 cm, about two inches, away from the umbilicus, at 90 degrees, do not aspirate, and do not massage, because both increase hematoma risk. Rotate sites. Low molecular weight heparin such as enoxaparin comes in a prefilled syringe with an air bubble that is not expelled, and the skin fold is held throughout injection.
• Insulin: use an insulin syringe with units marked, inject at 90 degrees, do not aspirate, and do not massage. Absorption is fastest from the abdomen, then arm, then thigh, then buttock. Rotate within one anatomic region rather than across regions to keep absorption consistent, and space sites about 2.5 cm apart to prevent lipohypertrophy. When mixing, draw air into the intermediate-acting cloudy insulin first, then air into the clear regular insulin, then withdraw the clear regular insulin, then the cloudy: clear before cloudy. Insulin glargine, detemir, and degludec are never mixed with other insulins.

Intramuscular

• Ventrogluteal is the preferred adult site for volumes above 2 mL and for viscous or irritating medications. It is located by placing the palm on the greater trochanter, the index finger on the anterior superior iliac spine, and the middle finger along the iliac crest, then injecting into the V. It is free of major nerves and vessels.
• Deltoid holds about 1 mL, up to 2 mL in a well-developed adult, and is located 2.5 to 5 cm below the acromion process. It is the standard adult vaccine site. Injection too high or too deep risks shoulder injury and axillary nerve damage.
• Vastus lateralis is the preferred site for infants under 12 months and is acceptable at all ages. The dorsogluteal site is no longer recommended because of sciatic nerve injury risk.
• Z-track technique is now recommended for all intramuscular injections. Pull the skin laterally about 2.5 cm, insert at 90 degrees, inject slowly, wait about 10 seconds, withdraw, then release the skin so the tissue planes seal and medication cannot track back to the subcutaneous tissue. Do not massage.
• Routine aspiration before injection is no longer recommended for vaccines given in the deltoid or vastus lateralis. Facility policy and instructor expectation vary for other intramuscular medications, and aspiration remains a common expected answer for gluteal injections.

Never recap a used needle, activate the safety device immediately, and dispose of sharps at the point of use. Air bubbles are expelled before injection except when the manufacturer directs otherwise, as with prefilled enoxaparin.

Basic Intravenous Therapy

Site selection and insertion

Choose the most distal appropriate site in a nondominant upper extremity and move proximally with subsequent attempts, so that a failed site does not compromise a vein below it. Avoid areas of flexion, the antecubital fossa when other options exist, veins in an extremity with an arteriovenous fistula or graft, the side of a mastectomy with lymph node dissection, an extremity with lymphedema, a paralyzed or postcerebrovascular accident limb, and sites distal to a previous infiltration or phlebitis. Lower extremity veins are avoided in adults because of thrombosis risk.

Gauge selection: 14 to 16 for trauma and rapid volume resuscitation, 18 for blood products and surgery, 20 as a general-purpose adult size and acceptable for blood, and 22 to 24 for fragile, elderly, or pediatric veins. Prepare the skin with chlorhexidine using friction and let it dry completely; drying time is what kills organisms. Apply a tourniquet 10 to 15 cm above the site for no longer than a minute or two, insert bevel up at about 10 to 30 degrees, advance the catheter off the needle after blood return, release the tourniquet, connect and flush, and secure with a sterile transparent dressing labeled with date, time, gauge, and initials.

Peripheral catheters are changed based on clinical indication rather than a fixed schedule in most current guidance, and any catheter inserted under emergency conditions with questionable asepsis is replaced as soon as feasible.

Fluids

• Isotonic fluids such as 0.9 percent sodium chloride and lactated Ringer stay in the extracellular space and expand circulating volume. Used for hypovolemia and shock. Watch for fluid overload in heart failure and renal disease. Normal saline is the only solution compatible with blood products. Lactated Ringer is avoided in significant liver disease and in hyperkalemia caution contexts.
• Hypotonic fluids such as 0.45 percent sodium chloride shift water into cells. Used for cellular dehydration and hypernatremia. Contraindicated in increased intracranial pressure and in burns, where they worsen edema.
• Hypertonic fluids such as 3 percent sodium chloride, dextrose 10 percent, and dextrose 5 percent in 0.9 percent sodium chloride pull fluid into the vascular space. Used for severe hyponatremia and cerebral edema. Infuse slowly through a large vein with frequent neurologic and sodium monitoring, and watch for fluid overload.
• Dextrose 5 percent in water is isotonic in the bag but becomes effectively hypotonic once the dextrose is metabolized, so it is not used for resuscitation and is avoided in patients at risk for cerebral edema.

Potassium chloride is never given by intravenous push and is always diluted and infused by pump, with typical peripheral concentration and rate limits and continuous monitoring; rapid potassium administration causes fatal dysrhythmia.

Complications and immediate actions

• Infiltration: nonvesicant fluid leaks into tissue. Coolness, pallor, swelling, slowed rate, and no blood return. Stop the infusion, discontinue the catheter, elevate the limb, and apply a warm or cool compress per protocol.
• Extravasation: the same event with a vesicant such as a vasopressor or many chemotherapy agents. Stop the infusion, leave the catheter in place initially, aspirate residual drug, notify the provider, and give the specific antidote such as phentolamine for norepinephrine extravasation. This causes tissue necrosis.
• Phlebitis: redness, warmth, pain, and a palpable cord along the vein. Discontinue, apply warm compress, and restart in the opposite extremity.
• Local or bloodstream infection: purulence at the site, fever, chills. Discontinue, culture as ordered, and notify.
• Fluid overload: dyspnea, crackles, jugular venous distension, bounding pulse, rising blood pressure, and weight gain. Slow the infusion to keep the vein open, raise the head of the bed, administer oxygen, notify the provider, and anticipate a diuretic.
• Air embolism: sudden dyspnea, chest pain, hypotension, tachycardia, and altered mental status. Clamp the line, place the patient on the left side in Trendelenburg to trap air in the right ventricular apex, administer 100 percent oxygen, and notify the provider immediately.
• Speed shock: systemic reaction to a bolus given too rapidly, with flushing, headache, chest tightness, irregular pulse, and possible cardiac arrest. Stop the infusion and support the patient.
• Catheter embolism: suspected when the removed catheter tip is not intact. Apply a tourniquet high on the extremity, place the patient on the left side, and notify immediately.

Central venous access

Central venous access devices include nontunneled central catheters, tunneled catheters, implanted ports, and peripherally inserted central catheters. Tip position in the lower superior vena cava must be confirmed radiographically before first use. Central access is required for vesicants, parenteral nutrition, solutions with high osmolarity, and long-term therapy.

Infection prevention bundle: hand hygiene, maximal sterile barrier precautions at insertion, chlorhexidine skin antisepsis with full drying time, optimal site selection with the femoral site avoided in adults, scrubbing the needleless connector for the specified time before each access, sterile dressing changes at defined intervals or whenever the dressing is damp, loose, or soiled, and daily review of whether the line is still necessary. Prompt removal of an unnecessary line is the most effective single measure.

Air embolism prevention during insertion and removal of a central catheter: position the patient supine or in Trendelenburg when the anatomy allows, have the patient perform the Valsalva maneuver or exhale during removal, and apply an occlusive petroleum-based dressing to the exit site afterward, keeping the patient flat briefly. Immediately after subclavian or internal jugular insertion, the nurse assesses for pneumothorax, watching for sudden dyspnea, chest pain, diminished breath sounds on the affected side, and tracheal deviation.

Flushing uses a pulsatile push-pause technique with preservative-free normal saline, and clamping is timed to maintain positive pressure appropriate to the connector type. A blood return should be present before administration; absent return may indicate a fibrin sheath or thrombus and is reported rather than forced. Never use a small syringe such as 1 or 3 mL to force a clot, because the smaller barrel generates dangerously high pressure and can rupture the catheter.

Blood administration

Verify a signed consent and a patent large-gauge access, prime only with 0.9 percent sodium chloride using Y-tubing with a filter, and complete a two-person verification of the patient identifiers, blood type, unit number, and expiration. Obtain baseline vital signs, begin slowly, and remain with the patient for the first 15 minutes because most severe reactions occur early. Recheck vital signs per policy and complete the unit within four hours.

If a transfusion reaction is suspected, stop the transfusion immediately, disconnect the blood tubing and maintain the line with normal saline using new tubing, assess the patient and take vital signs, notify the provider and blood bank, and return the unit and tubing with a post-transfusion blood and urine specimen. Acute hemolytic reaction presents with fever, chills, flank or back pain, hypotension, and dark urine. Febrile nonhemolytic reaction produces fever and chills. Allergic reaction produces urticaria and itching, and anaphylaxis produces bronchospasm and hypotension. Transfusion-associated circulatory overload produces dyspnea and crackles, while transfusion-related acute lung injury produces hypoxemia and bilateral infiltrates without volume overload.

Prioritization Framework for Skill-Based Items

When an exam item asks what the nurse does first, apply this order:

1. Airway, breathing, circulation, then disability and level of consciousness.
2. Acute and unstable before chronic and stable, actual problems before potential ones.
3. Assess before intervening, unless the situation is a known emergency with a standing first action, such as stopping a transfusion or clamping a line for suspected air embolism.
4. Protect the patient from immediate harm before notifying anyone. Notification is rarely the very first action if the nurse can do something for the patient now, but it is the correct action when the required intervention exceeds the nurse's scope or requires an order.
5. For practical and vocational nurse items, ask whether the finding falls outside the established plan of care or reflects a change in status. If it does, the answer is to notify the registered nurse or provider.

Documentation

Document what was done, when, by whom, the assessment before and after, the patient's tolerance, patient education provided, and any notification made with the name of the person notified and their response. Document objective findings, use measurements rather than adjectives, chart after the fact rather than in advance, never chart for another person, and correct errors with a single line, initials, and date rather than obliteration. Incident or occurrence reports are internal quality documents and are not referenced in the medical record.

This page is independent study material for nursing licensure exam preparation. NCLEX-RN® and NCLEX-PN® are registered trademarks of the National Council of State Boards of Nursing (NCSBN). This content is not produced, reviewed, or endorsed by NCSBN. Always verify clinical information against current facility policy, drug references, and your nursing program's curriculum before applying it in practice.