NURSING SKILLS UWORLD Exam Questions And Correct Verified Answers 2026 Updated Version
The nurse working in an intensive care unit receives a prescription from the primary health care
provider to discontinue a triple-lumen subclavian central venous catheter. Which interventions will
help prevent air embolism on removal? Select all that apply.
1. Applying an air-occlusive dressing
26
2. Instructing the client to bear down
20
3. Instructing the client to lie in a supine
ly
position
Ju
4. Pulling the line harder if there is resistance
ng
5. Pulling the line out when the client is
inhaling
si
ur
123
To prevent air embolism when discontinuing a central venous catheter, the nurse should perform the
following interventions:
N
·Instruct the client to lie in a supine position. This will increase the central venous pressure
and decrease the possibility of air getting into the vessel (Option 3).
·Instruct the client to bear down or exhale. The client should never inhale during removal of
the line; inhalation will suck more air into the blood vessel via negative suction pressure
(Options 2 and 5).
· Apply an air-occlusive dressing (usually gauze with a Tegaderm dressing) to help prevent a
delayed air embolism. If possible, the nurse should attempt to cover the site with the
occlusive dressing while pulling out the line (Option 1).
,2|Page
● Pull the line cautiously and never pull harder if there is resistance. Doing so could
cause the catheter to break or become dislodged in the client's vessel (Option 4).
Educational objective:
To prevent air embolism when discontinuing a central venous catheter, it is important for the
nurse to pull the line cautiously, have the client in a supine position, have the client bear
down or exhale, and apply an air-occlusive dressing.
26
2,The nurse prepares to insert a large-bore nasogastric tube for gastric decompression.
After obtaining equipment, the nurse identifies the client, performs hand hygiene, applies
20
clean gloves, assesses nares, and selects a naris. Place the remaining steps in the correct
order. All options must be used.
ly
Ju
ng
si
ur
N
,3|Page
26
20
ly
Ju
Steps for inserting a nasogastric tube for gastric decompression include the
ng
following:
1. Perform hand hygiene and apply clean gloves (no need for sterile gloves)
2. Place client in high Fowler's position
si
3. Assess nares and oral cavity and select naris
4. Measure and mark the tube
ur
5. Curve 4-6" tube around index finger and release
6. Lubricate end of tube with water-soluble jelly
7. Instruct client to extend neck back slightly
8. Gently insert tube just past nasopharynx, aiming tip downward
N
9. Rotate tube slightly if resistance is met, allowing rest periods for client
10. Continue insertion until just above oropharynx
11. Ask client to flex head forward and swallow small sips of water (or dry if NPO)
12. Advance tube to marked point
13. Verify tube placement and anchor - use agency policy and procedure to verify
placement by anchoring tube in place and obtaining an abdominal x-ray.
Aspirating gastric contents and testing the pH may also give an indication of
placement (pH should be 5.5 or below). Auscultation of inserted air is
acceptable for confirming tube placement initially, but is not definitive as it is
, 4|Page
not an evidence-based method. Nothing may be administered through the
tube until x-ray confirmation is obtained, or this may cause aspiration.
Educational objective:
Key steps when inserting a large-bore nasogastric tube include using clean gloves;
inspecting nares; measuring, marking, and lubricating tube; instructing client to
extend the neck back slightly; inserting tube past the nasopharynx and continuing
advancement until just above oropharynx; asking the client to flex the head forward
and swallow; advancing tube to marked point; and verifying tube placement using
26
abdominal x-ray and anchoring.
20
ly
Ju
ng
si
ur
N
The nurse working in an intensive care unit receives a prescription from the primary health care
provider to discontinue a triple-lumen subclavian central venous catheter. Which interventions will
help prevent air embolism on removal? Select all that apply.
1. Applying an air-occlusive dressing
26
2. Instructing the client to bear down
20
3. Instructing the client to lie in a supine
ly
position
Ju
4. Pulling the line harder if there is resistance
ng
5. Pulling the line out when the client is
inhaling
si
ur
123
To prevent air embolism when discontinuing a central venous catheter, the nurse should perform the
following interventions:
N
·Instruct the client to lie in a supine position. This will increase the central venous pressure
and decrease the possibility of air getting into the vessel (Option 3).
·Instruct the client to bear down or exhale. The client should never inhale during removal of
the line; inhalation will suck more air into the blood vessel via negative suction pressure
(Options 2 and 5).
· Apply an air-occlusive dressing (usually gauze with a Tegaderm dressing) to help prevent a
delayed air embolism. If possible, the nurse should attempt to cover the site with the
occlusive dressing while pulling out the line (Option 1).
,2|Page
● Pull the line cautiously and never pull harder if there is resistance. Doing so could
cause the catheter to break or become dislodged in the client's vessel (Option 4).
Educational objective:
To prevent air embolism when discontinuing a central venous catheter, it is important for the
nurse to pull the line cautiously, have the client in a supine position, have the client bear
down or exhale, and apply an air-occlusive dressing.
26
2,The nurse prepares to insert a large-bore nasogastric tube for gastric decompression.
After obtaining equipment, the nurse identifies the client, performs hand hygiene, applies
20
clean gloves, assesses nares, and selects a naris. Place the remaining steps in the correct
order. All options must be used.
ly
Ju
ng
si
ur
N
,3|Page
26
20
ly
Ju
Steps for inserting a nasogastric tube for gastric decompression include the
ng
following:
1. Perform hand hygiene and apply clean gloves (no need for sterile gloves)
2. Place client in high Fowler's position
si
3. Assess nares and oral cavity and select naris
4. Measure and mark the tube
ur
5. Curve 4-6" tube around index finger and release
6. Lubricate end of tube with water-soluble jelly
7. Instruct client to extend neck back slightly
8. Gently insert tube just past nasopharynx, aiming tip downward
N
9. Rotate tube slightly if resistance is met, allowing rest periods for client
10. Continue insertion until just above oropharynx
11. Ask client to flex head forward and swallow small sips of water (or dry if NPO)
12. Advance tube to marked point
13. Verify tube placement and anchor - use agency policy and procedure to verify
placement by anchoring tube in place and obtaining an abdominal x-ray.
Aspirating gastric contents and testing the pH may also give an indication of
placement (pH should be 5.5 or below). Auscultation of inserted air is
acceptable for confirming tube placement initially, but is not definitive as it is
, 4|Page
not an evidence-based method. Nothing may be administered through the
tube until x-ray confirmation is obtained, or this may cause aspiration.
Educational objective:
Key steps when inserting a large-bore nasogastric tube include using clean gloves;
inspecting nares; measuring, marking, and lubricating tube; instructing client to
extend the neck back slightly; inserting tube past the nasopharynx and continuing
advancement until just above oropharynx; asking the client to flex the head forward
and swallow; advancing tube to marked point; and verifying tube placement using
26
abdominal x-ray and anchoring.
20
ly
Ju
ng
si
ur
N
