Clinical Skills; Essential Collection
questions with correct answers
Applying Elastic Stockings - ANS ✔✔Before: Assess for risk factors in Virchow's triad (stasis of
blood flow, endothelial injury, hyper coagulability), supine position with the head of the bed
elevated, if they have been sitting or walking, elevate feet for 15-20 mins before applying,
assess pedal and popliteal pulses.
Purpose: Antiembolic stockings and sequential compression devices are used in the prevention
of deep vein thrombosis (DVT), which is one type of venous thromboembolism (VTE), Elastic
stockings help prevent blood stasis and venous wall injury by promoting venous return and
limiting venous dilation-> decreases the risk of endothelial tears
Contraindications: Dermatitis, open lesions, recent skin graft to lower legs, decreased arterial
circulation in lower extremities
Delegation: delegated to NAP only after nurse determines size and assesses patients lower
extremities. Tell NAP to report if one calf appears larger than another and if calf is red but not
hot.
Monitoring: Tell patient not to partially roll stockings down, remove once per shift and inspect,
notify provider about suspected DVT
Applying Restraints - ANS ✔✔ALERT
Place the patient in the lateral position, or elevate the head of the bed. The patient with
extremity restraints is at risk for aspiration if placed in the supine position.
Use a quick release tie to secure the restraint.
Ensure that the restraint does not interfere with equipment, such as an IV, and is not placed
over an access device, such as an arteriovenous shunt.
,Do not attach the straps of a restraint to the side rails of the bed.
Do not tie the straps of a restraint into a knot.
Check the skin under the restraint for abrasions.
Change wet or soiled restraints to prevent skin breakdown.
Remove a restraint immediately if the patient has an alteration in neurovascular status of an
extremity, such as cyanosis, pallor, or coldness of the skin, or if the patient complains of tingling,
pain, or numbness in the restrained extremity.
DELEGATION
The application and routine checking of a restraint, however, can be delegated to NAP. The Joint
Commission14 requires that anyone who monitors a restrained patient, including NAP, be
trained in first aid. Be sure to inform NAP of the following:Correct placement of the restraint
and how to routinely check the patient's circulation, skin condition, and breathing.When and
how to change a patient's position or provide range-of-motion exercises, toileting, and skin care.
To notify you immediately if there is a change in the level of the patient's agitation, skin
integrity, circulation of the extremities, or breathing.
MONITORING AND CARE
After applying a restraint, evaluate the patient's condition for signs of injury every 15 minutes.
Remove the restraints at least every 2 hours, and assess the placement of the restraint, patient's
circulation, skin condition, position and provide range of motion exercise, toileting and skin
care.
Evaluate the patient for any complications of
Providing Enteral Feedings - ANS ✔✔ALERT
Maintaining and monitoring the tube location during feeding and keeping the head-of-bed
elevation at a minimum of 30 degrees-and preferably 45 degrees-reduces aspiration incidents
and subsequent pneumonia.
Do not adjust the feeding rate; infuse the feeding as ordered.
A sudden gain of more than 2 pounds in 24 hours usually indicates fluid retention.
, If the patient aspirates formula, do the following:
Report the change in patient condition to the health care provider; if there has not been a
recent chest x-ray film, suggest ordering one.
Prepare for possible initiation of antibiotics.
If the patient develops nausea and vomiting, which may indicate paralytic ileus:
Withhold the tube feeding, and notify the health care provider.
Be sure that the tube is patent; aspirate for residual volume.
Never use standard Luer-Lok syringes for oral medications or enteral feedings; use oral syringes
for oral liquid medications or enteral feedings until enteral syringes with the new connector are
available.5
Remember to route tubes and catheters having different purposes in different, standardized
directions (e.g., IV lines routed toward the head; enteric lines toward the feet). This is especially
important in the care of neonates.5
To enhance patient safety and prevent tubing misconnections, a new industry-wide design
standard for enteral feeding connectors is being adopted. The ENFit connector is being phased
in for feeding tubes, feeding syringes, and feeding administration sets.
DELEGATION
The skill of administering a nasoenteric tube feeding can be delegated to NAP, according to your
agency's policy. However, a registered nurse (RN) or licensed practical nurse (LPN/LVN) must
first verify tube placement and patency. Be sure to inform NAP of the following:
Elevate the head of the bed at least 30 degrees, and preferably 45 degr
Managing a Nasogastric Tube - ANS ✔✔ALERT
Based on a patient's clinical condition and agency policy, check the feeding tube position at
regular intervals—often every 4 to 6 hours—and before administering formula or medications
through the tube.
Monitor the length of the tube externally, and observe the appearance, volume, and pH of the
fluid aspirated through the tube.
questions with correct answers
Applying Elastic Stockings - ANS ✔✔Before: Assess for risk factors in Virchow's triad (stasis of
blood flow, endothelial injury, hyper coagulability), supine position with the head of the bed
elevated, if they have been sitting or walking, elevate feet for 15-20 mins before applying,
assess pedal and popliteal pulses.
Purpose: Antiembolic stockings and sequential compression devices are used in the prevention
of deep vein thrombosis (DVT), which is one type of venous thromboembolism (VTE), Elastic
stockings help prevent blood stasis and venous wall injury by promoting venous return and
limiting venous dilation-> decreases the risk of endothelial tears
Contraindications: Dermatitis, open lesions, recent skin graft to lower legs, decreased arterial
circulation in lower extremities
Delegation: delegated to NAP only after nurse determines size and assesses patients lower
extremities. Tell NAP to report if one calf appears larger than another and if calf is red but not
hot.
Monitoring: Tell patient not to partially roll stockings down, remove once per shift and inspect,
notify provider about suspected DVT
Applying Restraints - ANS ✔✔ALERT
Place the patient in the lateral position, or elevate the head of the bed. The patient with
extremity restraints is at risk for aspiration if placed in the supine position.
Use a quick release tie to secure the restraint.
Ensure that the restraint does not interfere with equipment, such as an IV, and is not placed
over an access device, such as an arteriovenous shunt.
,Do not attach the straps of a restraint to the side rails of the bed.
Do not tie the straps of a restraint into a knot.
Check the skin under the restraint for abrasions.
Change wet or soiled restraints to prevent skin breakdown.
Remove a restraint immediately if the patient has an alteration in neurovascular status of an
extremity, such as cyanosis, pallor, or coldness of the skin, or if the patient complains of tingling,
pain, or numbness in the restrained extremity.
DELEGATION
The application and routine checking of a restraint, however, can be delegated to NAP. The Joint
Commission14 requires that anyone who monitors a restrained patient, including NAP, be
trained in first aid. Be sure to inform NAP of the following:Correct placement of the restraint
and how to routinely check the patient's circulation, skin condition, and breathing.When and
how to change a patient's position or provide range-of-motion exercises, toileting, and skin care.
To notify you immediately if there is a change in the level of the patient's agitation, skin
integrity, circulation of the extremities, or breathing.
MONITORING AND CARE
After applying a restraint, evaluate the patient's condition for signs of injury every 15 minutes.
Remove the restraints at least every 2 hours, and assess the placement of the restraint, patient's
circulation, skin condition, position and provide range of motion exercise, toileting and skin
care.
Evaluate the patient for any complications of
Providing Enteral Feedings - ANS ✔✔ALERT
Maintaining and monitoring the tube location during feeding and keeping the head-of-bed
elevation at a minimum of 30 degrees-and preferably 45 degrees-reduces aspiration incidents
and subsequent pneumonia.
Do not adjust the feeding rate; infuse the feeding as ordered.
A sudden gain of more than 2 pounds in 24 hours usually indicates fluid retention.
, If the patient aspirates formula, do the following:
Report the change in patient condition to the health care provider; if there has not been a
recent chest x-ray film, suggest ordering one.
Prepare for possible initiation of antibiotics.
If the patient develops nausea and vomiting, which may indicate paralytic ileus:
Withhold the tube feeding, and notify the health care provider.
Be sure that the tube is patent; aspirate for residual volume.
Never use standard Luer-Lok syringes for oral medications or enteral feedings; use oral syringes
for oral liquid medications or enteral feedings until enteral syringes with the new connector are
available.5
Remember to route tubes and catheters having different purposes in different, standardized
directions (e.g., IV lines routed toward the head; enteric lines toward the feet). This is especially
important in the care of neonates.5
To enhance patient safety and prevent tubing misconnections, a new industry-wide design
standard for enteral feeding connectors is being adopted. The ENFit connector is being phased
in for feeding tubes, feeding syringes, and feeding administration sets.
DELEGATION
The skill of administering a nasoenteric tube feeding can be delegated to NAP, according to your
agency's policy. However, a registered nurse (RN) or licensed practical nurse (LPN/LVN) must
first verify tube placement and patency. Be sure to inform NAP of the following:
Elevate the head of the bed at least 30 degrees, and preferably 45 degr
Managing a Nasogastric Tube - ANS ✔✔ALERT
Based on a patient's clinical condition and agency policy, check the feeding tube position at
regular intervals—often every 4 to 6 hours—and before administering formula or medications
through the tube.
Monitor the length of the tube externally, and observe the appearance, volume, and pH of the
fluid aspirated through the tube.
