In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of the potential for complications of diagnostic tests, treatments, and procedures in order to:

  • Assess client for an abnormal response following a diagnostic test/procedure (e.g., dysrhythmia following cardiac catheterization)
  • Apply knowledge of nursing procedures and psychomotor skills when caring for a client with potential for complications
  • Monitor the client for signs of bleeding
  • Position the client to prevent complications following tests/treatments/procedures (e.g., elevate head of bed, immobilize extremity)
  • Insert, maintain and remove a gastric tube
  • Insert, maintain and remove a urinary catheter
  • Insert, maintain and remove a peripheral intravenous line
  • Maintain tube patency (e.g., NG tube for decompression, chest tubes)
  • Use precautions to prevent injury and/or complications associated with a procedure or diagnosis
  • Provide care for client undergoing electroconvulsive therapy (e.g., monitor airway, assess for side effects, teach client about procedure)
  • Intervene to manage potential circulatory complications (e.g., hemorrhage, embolus, shock)
  • Intervene to prevent aspiration (e.g., check NG tube placement)
  • Intervene to prevent potential neurological complications (e.g., foot drop, numbness, tingling)
  • Evaluate responses to procedures and treatments

Assessing the Client for an Abnormal Response Following a Diagnostic Test/Procedure

Practically all diagnostic tests and procedures can lead to complications, particularly when these tests and procedures are invasive.

Cardiac dysrhythmias can result from a cardiac catheterization; therapeutic radiation for cancer treatment can lead to radiation pneumonitis and multiple systems fibrosis, skin erythema and skin sloughing; cancer chemotherapy can lead to alopecia, ulcerations of the oral mucous membranes, and an increased risk of infection.

Applying a Knowledge of Nursing Procedures and Psychomotor Skills When Caring for a Client with Potential for Complications

Nurses apply their knowledge of nursing procedures and psychomotor skills when caring for a client with the potential for complications. For example, a client undergoing a cardiac catheterization will be closely monitored for any cardiac arrhythmias; a client with a casted extremity may develop limb threatening compartment syndrome; the nurse will maintain asepsis for all care including the care of the client who is at risk for infection related to chemotherapy; and the nurse will keep the client up at least 30 degrees when they are getting a tube feeding to prevent aspiration.

Monitoring the Client for Signs of Bleeding

Hemorrhage and bleeding are risk factors associated with all invasive surgical procedures and treatments as well as diseases and disorders such as leukemia, cirrhosis, gastrointestinal tract ulcers, disseminated intravascular coagulation, hemophilia, inflammatory bowel disease, esophageal varices, and stress ulcers.

When severe, hemorrhage and excessive bleeding can lead to hypovolemic shock. The stages of hypovolemic shock are the initial stage, the compensatory stage, the progressive stage and the refractory and irreversible stage.

The signs and symptoms of hypovolemic shock vary according to the stage of the shock; some of the signs and symptoms include hypotension, tachycardia, a lack of tissue perfusion, hyperventilation, decreased cardiac output, decreased urinary output, oliguria, anuria, metabolic acidosis, increased blood viscosity, and multisystem failure.

The goal of treatments for hypovolemic shock include the correction of the underlying cause, fluid replacements including lactated Ringer's solution, blood and blood products as indicated, placing the client into the Trendelenburg position, and plasma expanders. The lack of effective treatment can lead to death.

Nurse must perform ongoing assessments and reassessments including the monitoring of diagnostic laboratory data, the client's intake and output, vital signs, central venous pressure, arterial blood gases, renal functioning and hemodynamic monitoring.

Positioning the Client to Prevent Complications Following Tests, Treatments, and Procedures

Clients are positioned during and after many diagnostic tests, treatments and procedures. For example the head of the bed is elevated when the client has a tube feeding, the client remains flat and in the supine position after a spinal tap, the client will be protected from any pressure after an extremity is immobilized with a cast until it is completely dried.

Inserting, Maintaining and Removing a Gastric Tube

The insertion, maintenance and removal of a gastric tube are discussed below:

Inserting a Nasogastric Tube

As with all procedures, the nurse must verify the order, accurately identify the client using two unique identifiers, and explain the procedure to the client.

The supplies and equipment that will be needed to insert a nasogastric tube include globes, the nasogastric tube, a water soluble jelly, a topical anesthetic, tape to secure the tube, a small cup of water, a drinking straw, a 60 mL catheter tipped syringe, and a suction machine and tubing when ordered.

  • Place the client in a high Fowler's position and inspect the nares.
  • Select the best nare.
  • Measure the nasogastric tube from the nose to the earlobe to tip of xiphoid. Mark the nasogastric tube with the tape.
  • Apply the topical anesthetic and the water soluble lubricant to the tip of the nasogastric tube.
  • Give the client the small cup of water and the straw if they are safe to drink it when you ask them to.
  • Have the client to look up so that their neck is hyperextended upward.
  • Advance the nasogastric tube until you meet some resistance at the nasopharynx.
  • Continue to advance the tube below the curve of the nasopharynx as the client now takes small sips of water while they are leaning forward.
  • Check for the correct placement of the nasogastric tube.
  • Secure the nasogastric tube to the nose with tape.
  • Secure the tubing to the client's gown with a safety pin.
  • Clamp the tube or connect it to the suction device if ordered.

Removing the Nasogastric Tube

Again, the nurse must verify the order, accurately identify the client using two unique identifiers, and explain the procedure to the client.

  • Remove the securing tape anchor from the nose.
  • Remove the safety pin from the client's
  • Disconnect the tubing from suction and/or clamp it.
  • Ask the client to take a deep breath as you pull the tube out.
  • Clean the client's nares and provide oral hygiene to the client.

Maintaining a Nasogastric Tube

Maintenance of a nasogastric tube consists of daily nare care, mouth care, and monitoring the tube patency. All nasogastric drainage is measured and documented in terms of amount, color and other characteristics. If the nasogastric tube is used for feedings or medication administration, it must be irrigated before and after each feeding or medication.

Inserting, Maintaining and Removing a Urinary Catheter

The insertion, maintenance and removal of a urinary catheter were previously discussed under the section entitled "Using Alternative Methods to Promote Voiding".

Inserting, Maintaining and Removing a Peripheral Intravenous Line

The procedures for inserting and maintaining peripheral intravenous lines were previously discussed in the sections entitled "Educating the Client on the Reason For and Care of a Venous Access Device" and "Monitoring the Intravenous Infusion and Maintaining the Site", respectively.

The removal of a peripheral intravenous line is done with these steps:

  • Turn off and disconnect any intravenous fluids.
  • Remove the site dressing.
  • Gently withdraw the peripheral intravenous catheter and check it for any breakage or deterioration.
  • Inspect the site and cover it with an adhesive bandage.
  • Document the removal of the peripheral intravenous line.

Maintaining Tube Patency

Nurses monitor and maintain the patency of a wide variety of tubes and catheters including nasogastric tubes, chest tubes. The simplest way to prevent an inpatent tube or line is to insure that it is not kinked or obstructed in any way.

Nasogastric Tube Patency

Nasogastric tubes should be irrigated before and after each medication administration and each intermittent tube feeding. These tubes are also irrigated according to the particular facility's policy and procedure when a continuous tube feeding is being given.

Chest Tube Patency

After the first 24 hours after placement, chest tubes are assessed and monitored in terms of their functioning, patency, the fluid levels and the characteristics of drainage at least every hour; and then at least every eight hours after the initial first 24 hours.

Artificial Airway Tube Patency

Endotracheal and Tracheostomy Tubes

Generally speaking, airway tubes such as endotracheal and tracheostomy tubes are monitored and maintain to insure proper placement and patency. Patency is maintained with the validation that the tube is correctly placed and the provision of humidity and suctioning, as indicated.

Suctioning is done with a suctioning vacuum source that can be part of the facility's central suctioning system or a portable suctioning machine that is used in the home, for example. Suctioning catheters come in different sizes. The largest possible suctioning catheter should be used whenever possible. Suctioning catheters range in size from 5 Fr, which is the smallest suctioning catheter, and up to 16 Fr, which is the largest suctioning catheter in terms of diameter.

The typical sizes of suctioning catheters for the different age groups along the life span are:

  • Adults: 10 to 16 Fr
  • Pediatric Clients From 1 1/2 Years of Age Through Adolescence: 10 to 16 Fr
  • Neonates and Infants Less Than 1 1/2 Years of Age; 5 to 8 Fr

Suctioning is a sterile procedure. Artificial airway suctioning can be done with open airway suctioning and closed airway suctioning. Open airway suctioning is done while the client is breathing room air without oxygen; and closed airway suctioning is done when the client is receiving supplemental oxygen. The latter is the preferred method because pre procedure oxygenation and the administration of oxygen during suctioning prevents hypoxia during the suctioning episode. Suctioning episodes should be done as rapidly as possible because it can cause client anxiety as well as hypoxia.

The correct placement of an endotracheal tubes can be determined and validated in a number of different ways including:

  • Diagnostic capnography to detect for carbon dioxide when the client exhales
  • Diagnostic chest x-ray to validate the artificial airway's proper placement
  • Auscultating for the presence of breath sounds in both lung areas and NOT in the area of the stomach
  • Using an esophageal detection device to confirm proper placement
  • Inspecting the chest rise and fall in a symmetrical manner

The nurse will do the following things when a client with a tracheostomy tube has a partial or complete airway obstruction:

  • If the nurse cannot pass the suction catheter into the airway, the nurse should deflate the cuff
  • Attempt to advance the suction catheter with the cuff deflated. It the catheter is still meeting with resistance, it is highly possible that a mucous plug is obstructing the airway and interfering with the patency of the artificial airway
  • Remove the inner cannula of the tube and remove the mucous plug

Using Precautions to Prevent Injury and/or Complications Associated with a Procedure or Diagnosis

At times, special precautions are implemented to prevent injuries and complications associated with a procedure or diagnosis. As previously discussed, clients who are receiving continuous tube feedings are placed in a semi Fowler's position of at least 30 degrees to prevent aspiration, clients who have just had a cast applied to an extremity fracture will be monitored for compartment syndrome and they will be advised to NOT exert any pressure on the cast until it is completely dried to prevent denting which could lead to circulatory and neurological impairment; all preoperative clients are NPO prior to surgery to prevent aspiration, seizure precautions are initiated and maintained when the client has a seizure disorder, suctioning equipment and supplies are readily accessible and available at the bedside when the client is at risk for aspiration, special screenings and assessments are done to identify clients who are at risk for skin breakdown and/or falls, and nurses implement a wide variety of preventive measures and special precautions to prevent the many complications of immobility and inactivity, including contractures, urinary stasis and venous thrombosis.

Providing Care for a Client Undergoing Electroconvulsive Therapy

As somewhat discussed in the previous section entitled "Applying a Knowledge of Client Psychopathology to Mental Health Concepts Applied in Individual, Group and Family Therapy" nurses maintain client safety by maintaining the client as NPO at least for 6 hours prior to the electroconvulsant therapy procedure, they remove all items on or around the body like jewelry prior to the treatment, they initiate and/or maintain an open and patent intravenous line which can be used in an emergency, they administer pre therapy medications as ordered, they continuously monitor and assess the client, their vital signs, the induced seizure activity and they insure the client's safety during and after the electroconvulsant therapy procedure.

Additional nursing responsibilities before and after the electroconvulsant therapy procedure include client teaching related to the treatment, the purpose of the treatment, some of the side effects of the treatment, and what to expect before and after the procedure. Care after the electroconvulsant therapy procedure includes monitoring the client's physical status and reorienting the client because some confusion and amnesia can occur after the treatment. The nurse assesses the client's level of confusion and/or amnesia, they initiate and implement special precautions to maintain the client's safety and to protect them from accidents and injuries, and they also monitor and assess the client from some of the commonly occurring physiological side effects of the treatment including muscular soreness, changes in term of the client's cardiovascular status, a headache and hypertension.

Intervening to Manage Potential Circulatory Complications

Some of the circulatory complications associated with some tests, treatments and diagnostic tests include things such as thrombosis, hemorrhage and hypovolemic shock, cardiogenic shock, anaphylactic shock,.

Interventions for Thrombosis

The treatment for superficial cases of thrombosis includes bed rest, elevation of the extremity, local heat, and NSAIDs to prevent emboli and deep vein thrombosis. Deep vein thrombosis is treated with medications, such as anticoagulants, thrombin inhibitors, and thrombolytics. Other types of treatment include a vena cava filter, when indicated, and graduated compression stockings to increase peripheral venous return.

Interventions For Hypovolemic Shock and Hemorrhage

As previously stated in the sections entitled "Monitoring the Client for Signs of Bleeding" and "Assisting the Client in Receiving Appropriate End of Life Physical Symptom Management", the treatment of hypovolemic shock include the correction of the underlying disorder and:

  • The administration of blood and blood products and plasma expanders
  • The administration of fluid replacements including lactated Ringer's solution
  • Placing the client into the Trendelenburg position

Interventions For Cardiogenic Shock

Cardiogenic shock can occur secondary to a cardiac arrhythmia, as can occur after a diagnostic cardiac catheterization, a myocardial infarction, cardiomyopathy, cardiac valve disease and myocarditis. Cardiogenic shock leads to peripheral vasoconstriction to the vital organs of the body, hypotension, and tachycardia.

The treatment of cardiogenic shock aims to preserve life and to maintain adequate oxygen to the vital organs of the body including the brain and the heart muscle itself. These treatments and interventions can include:

  • Emergency cardiopulmonary resuscitation when indicated
  • Oxygen supplementation
  • Mechanical ventilation as indicated
  • The administration of aspirin or super aspirins, such as clopidogrel or a platelet glycoprotein IIb/IIIa receptor blockers
  • The administration of thrombolytics and anticoagulants like heparin
  • The administration of inotropic drugs
  • Angioplasty and stenting
  • The insertion of a balloon pump
  • Coronary artery bypass surgery
  • A ventricular assist heart pump
  • A heart transplant

Interventions For Anaphylactic Shock

Anaphylactic shock most frequently follows an allergic response to a medication such as penicillin, but it also can occur as the result of an insect bite, some foods like peanuts and shell fish, latex and some anesthetic drugs.

The signs and symptoms associated with anaphylactic shock include hypotension, massive circulatory relaxation, decreased cardiac output, laryngeal edema, respiratory distress and tachycardia.

The treatment for anaphylaxis is the immediate cessation of the offending medication and:

  • Emergency cardiopulmonary resuscitation when indicated
  • The administration of adrenaline or noradrenaline
  • Supplemental oxygen
  • The administration of cortisone and/or antihistamines
  • The administration of a beta agonist such as albuterol

Interventions For Neurogenic Shock

Neurogenic shock can occur as a result when the sympathetic nervous system shuts down. It is most often associated with a traumatic spinal cord injury but it can also occur as the result of treatment with a spinal anesthetic.

Neurogenic shock leads to the relaxation of the body's arterioles and venules; and it is characterized with fainting, syncope, hypotension and bradycardia which is a unique sign of neurogenic shock when compared to other types of shock.

The treatment of neurogenic shock includes fluid replacement, the administration of vasopressor drugs, such as dopamine, norepinephrine or phenylephrine.

Interventions For Septic Shock

Septic shock is associated with a high level of morbidity and mortality; this type of shock occurs as the result of a serious infection, most often the result of gram positive bacteria like streptococcus pneumoniae and staphylococcus aureus, although it can also be secondary to a gram negative bacterial like Escherichia coli, some viruses, and some fungus infections. All invasive procedures and treatments, including surgery, place the client at risk for infection and septic shock.

The signs and symptoms of septic shock include the classical signs of infection in addition to:

  • Hypotension secondary to massive vasodilation
  • Hypotension
  • Confusion
  • Metabolic acidosis
  • Respiratory alkalosis
  • Abnormal breath sounds like crackles and rales
  • A widened pulse pressure
  • Cardiac depression and decreased cardiac output
  • Peripheral vasoconstriction which can lead to microemboli
  • Muti-system failure and shut down

The treatments include:

  • Fluid replacements
  • Oxygen supplementation therapy
  • Mechanical ventilation and intubation, as indicated
  • The correction of the underlying disorder like the infection
  • The symptomatic treatment of the signs and symptoms of septic shock including the metabolic acidosis and respiratory alkalosis
  • Dialysis as indicated

Interventions For Obstructive Shock

A major embolus in a major circulatory vessel, a tension pneumothorax, aortic stenosis, and cardiac tamponade can lead to obstructive shock. Obstructive shock, left untreated, can lead to organ failure and death.

The treatment of obstructive shock includes the correction of any underlying condition like treating a pneumothorax with chest tube drainage and treating cardiac tamponade with a pericardiocentesis, in addition to fluid replacement therapy.

Intervening to Prevent Aspiration

Aspiration is a risk among clients of all age groups along the life span. For example, a neonate and an infant may aspirate vomitus and bottle feedings when a baby bottle is propped up and the infant is not attended to. Aspiration can occur among toddlers and young children when they place a foreign body or object into their mouth, and it can occur among adolescents and adults when they are eating solid foods, particularly when alcohol is being consumed during the meal. Older adults are also at risk because they may have a swallowing disorder. Aspiration can also occur as the result of therapeutic interventions such as tube feedings.

The prevention of aspiration among infants and children include NOT propping up baby bottles and turning infants and young children on their side when they are vomiting. Additionally, all parents must maintain a baby proof and child proof home that does not allow a young toddler or child to put small foreign bodies, line pieces of a toy into their mouth.

Aspiration secondary to tube feedings can be prevented by keeping the head of the client's bed up to 30 degrees, checking and monitoring residual before administering a tube feeding, and assessing the abdomen for any distention which can indicate the retention of nasogastric feeding contents.

Intervening to Prevent Potential Neurological Complications

Many treatments and procedures place a client at neurological complications. For example, dressings, casts, bandages, restraints, and other medical devices and equipment can cause neurological damage when they are applied too tightly.

Nurses, therefore, must monitor all constrictive medical equipment and devices to insure that they are not too tight and constrictive during their application and during the duration of time that they remain in place, particularly if there is any danger of swelling in the area. The nurse should be able to put 2 or 3 fingers under these constrictive devices to insure that they are not too tight. At times, the client may report numbness and tingling to the affected area and, at other times, the nurse may assess a change in the color of the skin and weak or absent pulses to the area that may indicate a complication associated with this complication.

Foot drop is a complication of immobility. This complication can be prevented with full range of motion exercises and the use of a foot boot to prevent this complication. Again, foot boots should be applied snuggly but not too tight.

Evaluating Responses to Procedures and Treatments

As discussed throughout this NCLEX-RN review book, nurses evaluate the outcomes of all care, treatments and procedures to determine whether or not they have been effective and whether or not the client goals and expected outcomes have been met.

The data collected during this evaluation includes subjective, objective, primary and secondary data including diagnostic test results, client's subjective comments, and other data collected by the nurse during their ongoing reassessments of the client and the comparison of this data to baseline data that were collected prior to care, a treatment or a procedure.


SEE - Reduction of Risk Potential Practice Test Questions