Priority Nursing Actions

Allens Test
Explain procedure to client
Apply pressure over ulna and radial arteries
Ask client to open and close hand repeatedly
Release pressure from ulna
Assess extremity color distal to pressure point
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Blood Sample
Check HCP order
Identify food, medication, and other factors affecting procedure
Identify client
Explain procedure
Draw blood
Apply pressure to puncture site
Send blood to lab
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Infection Suspected and Central Venous Catheter Site
Notify HCP
Remove catheter, prepare for possible restore in different location
Remove catheter tip and sent it to the lab
Obtain a blood culture from the client
Prepare for antibiotic administration
Document what happened, the action taken, and the clients response
Inserting IV line
Check HCP order, get correct materials
Select site/ palpate the vein for resilience
Clean skin with alcohol swab in circular motion
Stabilize vein below insertion site and puncture skin, observe for blood in flashback
chamber (in no blood is observed, try again but make sure to use a new kit)
Apply pressure above insertion w/ nondoment hand, retract catheter tubing, secure IV,
begin flow
Tape and secure IV, label (date/time)
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Removing IV line
Check HCP order
Turn off IV, remove dressing while stabilizing the catheter
Apply pressure with gauze and remove slowly
Apply pressure for 2-3 minutes
Inspect IV site
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Transfusion Reaction
Stop transfusion
KVO w/ Normal saline
Notify HCP
Stay w/ client and monitor vitals every 5 minutes
Administer emergency medications
Obtain urine specimen
Return tubing to blood bank
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Adult CPR (CAB= Compressions, airway, breathing)
Determine unconsciousness
Check pulse at carotid artery
Perform chest compressions
Open airway, using the head tilt- chin lift
Check breathing and deliver breaths
Administering Medication via a Nasogastric Tube
Check order
Pre medication (make sure it can be crushed or if capsule, it can be opened)
Dissolved medication in 15-30 mL of water
Verify client and explain procedure
Check tube placement, check residual content and bowel sounds
Draw medication into a catheter- tip syringe, clear excess air from syringe, insert
medication into tube
Flush tube with 30-15 Ml of water or N.S.
Clamp tube for 30-60 minutes
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Eclampsia
Remain w/ client, call for help
Ensure open airway, turn client on side, give oxygen by mask at 8-10 L/min
Monitor fetal heart patterns
Administer medications as prescribed to control seizures
After seizure has ended, insert oral airway and suction as needed
Prepare for delivery
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Prolapse Cord
Apply finger pressure w/ gloved hand
Put client in trendelenburgs or modified sims or knee- chest position
Give oxygen at 8-10 L/min by face mask
Monitor FHR and assess the fetus for hypoxia
Prepare IV fluids or increase rate of existing solution
Prepare for immediate birth
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Major Burn Injury in Children

Stop burning process
Assess ABCs
Begin resuscitation if not breathing
Remove clothing/ jewelry
Cover wound w/ clean cloth
Keep warm
Transport to emergency department
Adult w/ Burns
Assess airway
Administer oxygen as prescribed
Obtain vitals
Initiate an IV line and begin fluid replacement as prescribed
Elevate extremities if no fractures are obvious
Keep client warm, client on NPO status
Adult/Child with Diabetes Mellitus Experiences Hypoglycemia
Check blood glucose level
Give cup fruit juice
Take vitals
Recheck blood glucose level
Give small snack of carbohydrates and protein
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Hypercyanotic Spell in an Infant
Place child in a knee- chest position
Administer 100% oxygen
Administer morphine sulfate
Administer fluids intravenously
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Anaphylactic Reaction from Medication
Assess respiratory status
Stop medication
Contact HCP and Rapid Response Team
Administer oxygen
Maintain IV access w/ N.S.
Raise clients feet/ legs of not contraindicated
Administer prescribed emergency medication
Monitor vitals
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Drawing up Insulin
Wash hands
Gently rotate NPH insulin bottle
Wipe off tops of insulin vials w/ alcohol sponge
Draw back amount of air into syringe that equals total dose
Inject air equal to NPH vial
Inject air equal to regular insulin dose into regular insulin vial
Draw up regular insulin
Draw up NPH insulin
Paracentesis
Obtain consent
Obtain vitals, including weight
Have client void
Position client upright
Apply dressing to site
Monitor vitals, weigh client, client should be on bed rest
Measure amount of fluid
Label and send fluid to lab for analysis
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Respiratory Suctioning
Explain procedure to client
Assist client to upright position
Perform hand hygiene and don protective garb
Prepare/ turn on suctioning equipment
Hyperoxygenate client
Insert catheter WITHOUT suction applied
Apply suctioning intermittently while ROTATING and WITHDRAWING the catheter
Hyperoxygenate client
Listen to breath sounds
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If Pulmonary Embolism if Suspected
Notify Rapid Response Team
Reassess the client and elevate HOB
Administer oxygen
Obtain vitals and check lung sounds
Prepare to obtain an ABG
Prepare to administer heparin therapy or other therapies
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If a Client Develops Pulmonary Edema

Place client in high fowlers
Administer oxygen
Assess client quickly, include assessing lung sounds
Ensure an intravenous access devise is in place
Prepare for the administration of a diuretic and morphine sulfate
Insert Foley as prescribed
Prepare for intubation and ventilator support, if required
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Hospitalized Client w/ Cardiac Disease Complaining of Chest Pain
QUICKLY assess client, characteristic of pain, heart rate/ rhythm, and blood pressure
Administer a nitroglycerin tablet
Stay with client
Reassess in 5 minutes
Administer another nitro tab if pain is not relieved and the BP is stable
Reassess in 5 mins, contact HCP if third nitro does not relieve pain
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Client Receiving Hemodialysis Develops an Air Embolism
Stop hemodialysis
Turn client on LEFT side w/ head DOWN ( Trendelenburgs)
Notify HCP
Administer oxygen
Assess vitals and pulse oximetry
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Client Sustains a Chemical Eye Injury
Irrigate the eye
Check pH of eye
Assess visual acuity
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Spinal cord Injury Client Who Develops Autonomic Dysreflexia (hyperreflexia)
Raise HOB
Loosen tight clothing on client
Check for bladder distention or other noxious stimulus
Administer antihypertensive medication
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Client Who Develops a Fat Embolism
Notify HCP
Administer oxygen
Administer IV fluids
Monitor vitals and respiratory status

 Prepare for intubation and mechanical ventilation if necessary

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Client Develops Anaphylaxis
QUICKLY assess respiratory status and maintain a patent airway
Call HCP and Rapid Response Team
Administer oxygen
Start IV line and infuse N.S.
Prepare to administer diphenhydramine (Benadryl) and epinephrine ( adrenaline)
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Action to Take For a Client Experiencing Anxiety
Provide a calm environment, decrease environmental stimuli, stay w/ client
Ask client to identify what and how they feel now
Encourage to discuss feelings
Help identify cause of feelings
Listen to client
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