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Study guide · Physiological Integrity

Reduction of Risk Potential

9 to 15% of the exam · 22 activity statements

Reduction of Risk Potential covers how the practical nurse lowers the chance that a client's condition, a diagnostic test or a procedure leads to harm: collecting specimens and vital signs, monitoring laboratory and diagnostic results, caring for tubes, catheters and IV lines, helping before and after procedures and surgery, and watching for early complications. NCLEX-PN items test whether you take measurements and specimens correctly, recognize a result or a change that matters and report what is outside your scope to the RN or provider.

A study feature written by ExamDragon, not part of the real exam. Each heading is one of the Related Activity Statements NCSBN lists for this category (22 of them), in our words; NCSBN's wording is in its Test Plan.

At a glance

Physiological Integrity
9 to 15%

of the exam (NCSBN's range)

Activity statements
22
Key terms
12

What this guide covers, statement by statement

  1. Spot client risks and act to reduce them
  2. Look for urine retention using a bladder scan, ultrasound or palpation
  3. Collect blood, urine, stool or sputum samples for testing
  4. Monitor nasogastric suction, whether continuous or intermittent
  5. Monitor results of diagnostic and lab tests
  6. Recognize signs of possible complications in pregnancy
  7. Do bedside tests such as pregnancy tests, troponin and urine dipsticks
  8. Check and interpret vital signs such as oxygen saturation and blood pressure
  9. Take steps to prevent harm or complications linked to a procedure or condition
  10. Do an ECG
  11. Help with diagnostic or invasive procedures
  12. Draw blood by venipuncture
  13. Apply compression stockings or SCDs and check they are used correctly
  14. Help care for clients before and after surgery
  15. Insert, look after and remove urinary catheters
  16. Insert, look after and remove nasogastric tubes
  17. Check blood glucose
  18. Look after central venous catheters
  19. Look after and remove peripheral IV lines
  20. Do focused data collection suited to the client's condition, such as neuro or circulation checks
  21. Monitor how the client reacts to treatments and procedures
  22. Reinforce teaching on procedures, treatments and equipment

1Spot client risks and act to reduce them

  • Collect data that identifies risk: fall history, confusion, weakness, sensory loss, new or multiple medications, invasive lines, and the client's own report.
  • Match the intervention to the risk: bed in low position, call light in reach, nonskid footwear, scheduled toileting, and clutter cleared for a fall risk.
  • Put known allergies, a bleeding risk, aspiration risk or a latex allergy where the team will see them, and apply the right alerts and bands.
  • Reassess risk when the client's condition or treatment changes, such as after sedation or a new antihypertensive.
  • Report a risk you cannot manage within your scope, and involve the RN for a new plan of care.
  • Prevention is the goal: act before the harm, not only after it.
  1. In practiceA newly admitted older client is unsteady, takes a sedative at night and has been to the bathroom twice in an hour. The practical nurse lowers the bed, puts the call light and urinal within reach, offers scheduled toileting and reports the fall risk to the RN so a plan is put in place.
  2. Where questions turnWaiting until after a fall to act on risks that were already visible on admission.
Practise this activity

2Look for urine retention using a bladder scan, ultrasound or palpation

  • Suspect urinary retention when a client has not voided in several hours, voids small frequent amounts, or has lower abdominal fullness and discomfort, especially after surgery or anesthesia.
  • A bladder scanner gives a noninvasive volume; palpation and percussion of a distended bladder support the finding.
  • Report a scanned residual above the facility threshold (often around 300 to 500 mL) so the RN or provider can decide on catheterization.
  • Review the intake and output record and recent medications, because opioids and anticholinergics can cause retention.
  • Offer measures that may help voiding first when appropriate: privacy, upright position, warm water over the perineum or the sound of running water.
  • Catheterization for retention needs a prescription; the practical nurse collects the data and reports.
  1. In practiceSix hours after surgery a client has not voided, feels the urge and has a firm, rounded lower abdomen. The practical nurse performs a bladder scan showing 550 mL, reports it to the RN and prepares for catheterization if prescribed.
  2. Where questions turnRecording a client as continent because small amounts are passing, when frequent small voids with a full bladder signal overflow from retention.
Practise this activity

3Collect blood, urine, stool or sputum samples for testing

  • Confirm the correct container, label at the bedside with two identifiers, and follow any timing, such as a first-morning or a 24-hour collection.
  • Clean-catch midstream urine: clean front to back, start the stream, then catch the sample; a sterile specimen from a catheter is taken from the sampling port, not the bag.
  • Blood cultures are drawn before the first antibiotic dose when possible, with careful skin antisepsis to avoid contamination.
  • Stool for ova and parasites or culture goes in the right container; do not let it sit, and note recent travel or antibiotics.
  • Sputum is collected on waking, from a deep cough rather than saliva; rinse the mouth with water first.
  • Send specimens promptly, store as required, and document the time and source.
  1. In practiceA provider orders urine and blood cultures for a client with a suspected infection. The practical nurse collects a clean-catch midstream urine and ensures the blood cultures are drawn before the first antibiotic dose, because antibiotics given first can make the cultures falsely negative.
  2. Where questions turnStarting the antibiotic before the ordered cultures are collected, which lowers the chance of identifying the organism.
Practise this activity

4Monitor nasogastric suction, whether continuous or intermittent

  • A nasogastric tube to suction removes stomach contents to decompress the stomach or rest the bowel; keep the ordered setting (continuous or intermittent, low or high).
  • Check that the tube is patent and in position, the suction is at the prescribed setting and the drainage is flowing, not static.
  • Measure and describe the drainage; report a sudden large increase, bright red blood or no drainage with distension.
  • Nasogastric suction removes fluid and electrolytes; watch for signs of low potassium and low chloride and metabolic alkalosis, and report them.
  • Keep the head of the bed raised, give mouth and nose care, and keep the client NPO unless the plan says otherwise.
  • Irrigate the tube with normal saline per policy to keep it patent, and report a tube that will not drain.
  1. In practiceA client with a nasogastric tube to low intermittent suction suddenly has no drainage and a distended, uncomfortable abdomen. The practical nurse checks the tubing for kinks and the suction setting, irrigates with saline per policy and reports to the RN if the tube still does not drain.
  2. Where questions turnRaising the suction to high because drainage stopped, instead of first checking placement, kinks and patency.
Practise this activity

5Monitor results of diagnostic and lab tests

  • Compare each result with its reference range and with the client's own trend; a value drifting toward danger matters even inside the range.
  • Know the results that need prompt reporting (each laboratory sets its own critical values): potassium below 3.0 or above 6.0 mmol/L, glucose low enough to need treatment (below 70 mg/dL) or very high, sodium far outside 135 to 145 mmol/L, and a very low platelet count.
  • Link the result to the client and the drugs: a low potassium with digoxin raises toxicity risk, a high INR with warfarin raises bleeding risk.
  • Report a critical value to the RN or provider at once, read it back if taken verbally, and document the report.
  • Notice a trend across several draws, such as a falling hemoglobin after surgery, not just the latest single value.
  • The practical nurse monitors and reports results; interpreting and changing the plan of care is the RN's and provider's.
  1. In practiceA client on furosemide and digoxin has a new potassium of 2.8 mmol/L. The practical nurse reports the critical value to the RN and provider at once and watches for signs of digoxin toxicity, because a low potassium makes the heart more sensitive to digoxin.
  2. Where questions turnFiling a critical potassium result to mention on rounds later instead of reporting it right away.
Practise this activity

6Recognize signs of possible complications in pregnancy

  • Report signs of a prenatal complication promptly: vaginal bleeding, a severe or persistent headache, blurred vision, epigastric pain, marked swelling of the face and hands, and reduced fetal movement.
  • A blood pressure of 140/90 or higher, protein in the urine and the above symptoms can mean preeclampsia, which needs urgent evaluation.
  • Painless bright red bleeding in later pregnancy can mean placenta previa; do not perform a vaginal examination, and report at once.
  • Painful dark bleeding with a rigid abdomen can mean placental abruption, an emergency.
  • Fever, burning on voiding or regular contractions before term are reported for evaluation.
  • The practical nurse collects data and reports; assessment and management of a complication belong to the RN and provider.
  1. In practiceA client at 34 weeks has a blood pressure of 158/96, a pounding headache and swollen hands. The practical nurse rechecks the blood pressure, keeps the client resting on her side, reports to the RN and provider at once and prepares for further evaluation, because these are signs of preeclampsia.
  2. Where questions turnTreating a late-pregnancy headache and swelling as normal discomfort instead of reporting possible preeclampsia.
Practise this activity

7Do bedside tests such as pregnancy tests, troponin and urine dipsticks

  • Point-of-care tests give a result at the bedside: capillary blood glucose, urine dipstick, urine pregnancy test, rapid strep, and troponin or others where policy allows.
  • Check the device and strips are in date and the meter is calibrated or quality-controlled per policy.
  • Use correct technique: the right drop size, timing and reading, and clean technique to avoid contaminating the sample.
  • Act on a critical result within the scope: report a very high or very low glucose and treat hypoglycemia per protocol.
  • Record the result, the time and the action, and send a confirmatory laboratory sample when required (for example a positive troponin).
  • Report an unexpected or critical point-of-care result to the RN or provider.
  1. In practiceA client with diabetes feels shaky and sweaty. The practical nurse checks a capillary glucose that reads 54 mg/dL, treats the hypoglycemia with a fast-acting carbohydrate per protocol, rechecks in 15 minutes and reports to the RN.
  2. Where questions turnRecording a point-of-care glucose without acting on a hypoglycemic value while the client is symptomatic.
Practise this activity

8Check and interpret vital signs such as oxygen saturation and blood pressure

  • Measure vital signs accurately: the right cuff size, an apical pulse for a full minute when it is irregular or for cardiac drugs, and respirations counted without the client's awareness.
  • Pulse oximetry needs a warm, well-perfused site and a good waveform; cold, nail polish or movement can give a false low reading.
  • Compare with the client's baseline and trend; a single value means less than a change over time.
  • Report readings outside safe limits: oxygen saturation below the ordered target, a systolic blood pressure much higher or lower than usual, a fast or very slow heart rate, or a high fever.
  • Check orthostatic blood pressure (lying, sitting, standing) when dizziness, falls or volume loss is a concern.
  • Recheck an abnormal value and the equipment before reporting, then report a confirmed change.
  1. In practiceA client's oxygen saturation reads 85% but the hands are cold and the waveform is poor. The practical nurse warms the hand, repositions the probe, gets a steady 92%, and still reports the value and the client's breathing to the RN while applying oxygen per protocol.
  2. Where questions turnReporting or acting on a low oxygen saturation from a cold finger or a poor waveform without first checking the probe.
Practise this activity

9Take steps to prevent harm or complications linked to a procedure or condition

  • Match the precaution to the procedure or diagnosis: aspiration precautions for a swallowing problem, bleeding precautions for a low platelet count or anticoagulation, seizure precautions for a client at risk.
  • Confirm the correct client, site and procedure, and that consent is in place, before an invasive test.
  • Position and prepare the client safely, keep the airway and circulation in view, and keep emergency equipment at hand for sedation.
  • After a procedure, follow the specific plan: pressure and bed rest after an angiogram, NPO until the gag reflex returns after an endoscopy, and the right position.
  • Teach and reinforce what the client should do and report, such as not to rub the eye after an eye procedure.
  • Report a complication of the procedure, such as bleeding, a falling blood pressure or a change in level of consciousness, to the RN or provider at once.
  1. In practiceAfter a liver biopsy the practical nurse positions the client on the right side with a pillow for pressure, keeps the client on bed rest, checks vital signs and the site on the schedule, and reports a rising heart rate with a falling blood pressure, because these can mean bleeding.
  2. Where questions turnLetting a client eat or drink right after an endoscopy before the gag reflex has returned, which risks aspiration.
Practise this activity

10Do an ECG

  • An ECG records the heart's electrical activity; the practical nurse performs the recording where policy allows and ensures a clear tracing.
  • Clean and prepare the skin, place the limb and chest leads in the correct positions, and ask the client to lie still and breathe normally.
  • Confirm the client's identity and the time on the tracing, and note symptoms such as chest pain at the time of the recording.
  • Recognize and report an obvious problem such as a very fast or very slow rate, or chest pain during the recording, without waiting for the formal read.
  • The provider or the RN interprets the ECG; the practical nurse ensures a quality tracing and reports urgent findings and symptoms.
  • Keep resuscitation equipment available for a client with chest pain or an unstable rhythm.
  1. In practiceA client reports chest pressure, and the practical nurse quickly obtains a 12-lead ECG with correct lead placement, notes the time and the symptom on the tracing and reports both to the RN and provider at once so it can be interpreted urgently.
  2. Where questions turnDelaying the ECG or the report while a client has active chest pain, instead of obtaining it and reporting the symptom immediately.
Practise this activity

11Help with diagnostic or invasive procedures

  • Confirm informed consent, the correct client, site and procedure, allergies and any needed NPO status before assisting.
  • Gather and set up the equipment with sterile technique where required, and position the client as the procedure needs (for example sitting and leaning forward for a thoracentesis).
  • Support the client during the procedure, watching breathing, color, pulse and comfort, and coach stillness and breathing.
  • Label and send any specimen correctly, and account for sharps and supplies.
  • After the procedure, apply the ordered dressing or pressure, check the site and vital signs, and keep the client in the ordered position.
  • Report a complication such as bleeding, dyspnea or a falling blood pressure at once; the provider performs the procedure and the RN manages complications.
  1. In practiceDuring a thoracentesis the practical nurse helps the client stay still leaning over a table, watches the color and breathing, and afterward checks the site and reports to the RN that the client suddenly became short of breath, because it can signal a pneumothorax.
  2. Where questions turnLeaving the bedside during an invasive procedure instead of staying to monitor the client's breathing and comfort.
Practise this activity

12Draw blood by venipuncture

  • Confirm the test, the client with two identifiers, and any special requirements such as fasting before drawing blood.
  • Apply the tourniquet no longer than about a minute, choose a suitable vein, and release it before full tube filling to limit changes in the sample.
  • Avoid an arm with a fistula or graft, a lymph node dissection or heavy scarring, and never draw above a running IV; below it only once the infusion is paused for the time policy sets.
  • Fill blood tubes in the correct order and invert additive tubes gently to prevent clotting or hemolysis.
  • Hold pressure until bleeding stops, longer for a client on anticoagulants, and check for a hematoma.
  • Label the tubes at the bedside and send them promptly; a mislabelled or hemolyzed sample must be redrawn.
  1. In practiceThe practical nurse needs blood from a client who has a dialysis fistula in the left arm and an IV in the right forearm. The nurse avoids the fistula arm entirely and draws from the right hand, below (distal to) the IV, after pausing the infusion for the time policy sets, or asks the RN or primary health care provider about another site; blood is never drawn above a running IV.
  2. Where questions turnDrawing blood from the arm with the dialysis access or from above a running IV, which can harm the access or give a diluted result.
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13Apply compression stockings or SCDs and check they are used correctly

  • Graduated compression stockings and sequential compression devices help prevent deep vein thrombosis in clients with limited mobility.
  • Measure the leg for the correct size, apply the stockings smoothly with no wrinkles or roll-down band, and check the skin under them.
  • Remove the stockings briefly each shift per policy to inspect and wash the skin, and reapply them.
  • Sequential compression sleeves are kept on except for bathing and skin checks, and are not used on a leg with a known deep vein thrombosis or severe peripheral arterial disease.
  • Check circulation, warmth, color and sensation of the toes, and report numbness, pain or a cold, pale foot.
  • Report calf pain, swelling, redness or warmth in one leg, which can signal a deep vein thrombosis.
  1. In practiceThe practical nurse applies correctly sized compression stockings to a postoperative client, smooths out the wrinkles, checks the toes for warmth and color, and later reports a newly swollen, warm, tender right calf to the RN.
  2. Where questions turnRolling a stocking down to the ankle, which creates a tight band that can cut off circulation, or applying a device to a leg with a suspected clot.
Practise this activity

14Help care for clients before and after surgery

  • Before surgery, confirm consent, allergies, NPO status, the site mark, removal of jewelry, dentures and nail polish, and that the ordered preparation is done.
  • Reinforce preoperative teaching: coughing and deep breathing, incentive spirometer, leg exercises and how pain will be managed.
  • Collect baseline vital signs and the checklist, and report an abnormal value or a new concern before the client goes to the operating room.
  • After surgery, monitor airway, breathing, circulation, the level of consciousness, the dressing and drains, pain and the return of protective reflexes.
  • Watch for complications: bleeding, a falling blood pressure, low urine output, fever, and signs of a clot; help the client turn, breathe deeply and move as allowed.
  • Report changes to the RN; the initial admission assessment and the plan of care remain the RN's.
  1. In practiceOn the first postoperative day the practical nurse helps the client use the incentive spirometer every hour while awake, checks the dressing and drains, encourages early ambulation with help, and reports a saturated dressing and rising heart rate to the RN.
  2. Where questions turnLetting a postoperative client stay still and skip deep breathing, which raises the risk of pneumonia and clots.
Practise this activity

15Insert, look after and remove urinary catheters

  • Insert a urinary catheter with sterile technique: correct size, cleaning the meatus, inflating the balloon only after urine returns, and securing the catheter.
  • Keep a closed drainage system, the bag below the bladder and off the floor, and the tubing free of kinks and dependent loops.
  • Give daily perineal care, keep the system closed, and remove the catheter as soon as it is no longer needed to lower infection risk.
  • Measure output, note color and clarity, and report cloudy or foul urine, no output, or new fever and flank pain.
  • Before removing, deflate the balloon fully; after removal, make sure the client voids within the expected time and report retention.
  • Report a catheter that will not drain or a client who cannot void after removal.
  1. In practiceA client's catheter bag has shown no urine for two hours. The practical nurse checks for kinks and a dependent loop, confirms the bag is below the bladder, and reports to the RN if the catheter still does not drain so obstruction or retention can be addressed.
  2. Where questions turnHanging the drainage bag at or above bladder level, which lets urine flow back and raises infection risk.
Practise this activity

16Insert, look after and remove nasogastric tubes

  • Measure the tube from the nose to the earlobe to the xiphoid process to estimate the length, and lubricate the tip with a water-soluble gel.
  • Insert with the client sitting upright, have the client swallow water (if allowed) as you advance, and stop if there is gagging, coughing or respiratory distress.
  • Confirm placement before use: an X-ray is the reliable method for initial placement; check the external length mark and, where policy uses it, aspirate pH at each use.
  • Secure the tube to the nose, mark the external length, and give nose and mouth care.
  • For removal, turn off suction, clear the tube, have the client take a breath and hold it, and withdraw the tube smoothly.
  • Report coughing, a drop in oxygen saturation or signs the tube has moved.
  1. In practiceWhile inserting a nasogastric tube, the practical nurse sees the client start coughing and the oxygen saturation drop. The nurse withdraws the tube, lets the client recover, then reattempts, because these signs can mean the tube entered the airway.
  2. Where questions turnContinuing to advance a nasogastric tube while the client coughs and desaturates, instead of withdrawing it at once.
Practise this activity

17Check blood glucose

  • Check blood glucose at the times ordered: before meals and at bedtime, before insulin, or when hypoglycemia or hyperglycemia is suspected.
  • Use a warmed, clean fingertip, the side of the finger, and a fresh lancet; a well-perfused site gives a better sample.
  • Confirm the meter and strips are in date and quality-controlled per policy.
  • Treat hypoglycemia (commonly below 70 mg/dL) per protocol with a fast-acting carbohydrate, recheck in about 15 minutes, and give a snack when the next meal is delayed.
  • Report a very high glucose, ketones, or a low glucose that does not improve with treatment.
  • Record the result, the time, the related insulin or food and the response.
  1. In practiceBefore breakfast a client's glucose is 58 mg/dL and the client feels shaky. The practical nurse gives 15 grams of a fast-acting carbohydrate, rechecks in 15 minutes to find 92 mg/dL, gives breakfast and documents the event and the response.
  2. Where questions turnGiving the scheduled mealtime insulin when the pre-meal glucose is already low, instead of treating the hypoglycemia first.
Practise this activity

18Look after central venous catheters

  • A central venous catheter ends in a large central vein; maintenance follows strict policy because infection and air embolism are serious risks.
  • Use sterile technique for dressing changes and cap changes, scrub the hub before access, and keep the dressing clean, dry and intact.
  • Flush as policy directs to keep the line patent, and clamp as required to prevent air entry.
  • Watch for signs of infection at the site and systemically, and report redness, drainage, fever or chills.
  • If air embolism is suspected (sudden dyspnea, chest pain, low blood pressure), clamp the line, place the client on the left side with the head down, give oxygen and call for help.
  • The practical nurse maintains the line within policy and scope; IV push through it is in most states the RN's (the PN gives it only where state law and facility policy allow), and many infusions remain the RN's.
  1. In practiceA client with a central line suddenly becomes short of breath and hypotensive after a cap change. The practical nurse clamps the catheter, places the client on the left side with the head lowered, applies oxygen and calls the RN, because these are signs of an air embolism.
  2. Where questions turnLeaving a central line open to air during a cap or tubing change, which can let air enter the central circulation.
Practise this activity

19Look after and remove peripheral IV lines

  • Check a peripheral IV site each shift and before use for infiltration (cool, swollen, pale), phlebitis (red, warm, tender along the vein) and patency.
  • Keep the dressing clean and dry, the site secured, and the line dated per policy; many sites are changed on a schedule or when there is a problem.
  • Flush as policy directs and verify blood return and easy flushing before giving fluids or medications.
  • For infiltration, stop the infusion and remove the catheter; for phlebitis, stop and remove it and apply warmth per policy; report either.
  • When removing a peripheral IV, stop the infusion, remove the catheter smoothly, apply pressure until bleeding stops and check that the catheter tip is intact.
  • Report a site you cannot restart, a catheter tip that looks broken, or signs of a serious reaction.
  1. In practiceThe practical nurse finds a client's IV site cool, swollen and pale with a sluggish drip. The nurse stops the infusion, removes the catheter, elevates the arm, documents the infiltration and reports to the RN so a new site can be started.
  2. Where questions turnFlushing harder to push past resistance in an IV site that is actually infiltrated, which forces fluid into the tissue.
Practise this activity

20Do focused data collection suited to the client's condition, such as neuro or circulation checks

  • Focused data collection targets the client's current problem: a neurological check for a head injury or stroke, a circulation check for a cast or vascular concern.
  • A neurological check covers level of consciousness, orientation, pupil size and reaction, movement and strength of each limb, and often a scale such as the Glasgow Coma Scale.
  • A circulation (neurovascular) check covers color, temperature, capillary refill, pulses, movement and sensation, compared side to side.
  • Compare each finding with the baseline and the other side, and watch the trend over your checks.
  • Report a falling level of consciousness, a new one-sided weakness, an unequal or fixed pupil, or a cold, pulseless, painful limb at once.
  • Do the checks on the ordered schedule and document them so a change is caught early.
  1. In practiceTwo hours after a forearm cast, the practical nurse finds the fingers cool and pale with slow capillary refill and the client reporting increasing pain and numbness. The nurse reports to the RN and provider at once, because these are signs of compromised circulation under the cast.
  2. Where questions turnChecking only the casted side without comparing it to the other limb, missing a developing circulation problem.
Practise this activity

21Monitor how the client reacts to treatments and procedures

  • Monitor how the client responds during and after a treatment or procedure: vital signs, comfort, breathing, bleeding and level of consciousness.
  • Compare the response with what is expected: pain relief after an analgesic, better breathing after a treatment, a stable blood pressure after a procedure.
  • Watch for an adverse response such as bleeding, a reaction, a falling blood pressure or a change in mental status, and act within scope.
  • Keep the client safe during recovery: side rails as needed, the call light in reach, and airway and circulation in view after sedation.
  • Document the response and what you reported, and reassess at the expected time.
  • Report a response that is worse than expected or a complication to the RN or provider.
  1. In practiceAfter a breathing treatment the practical nurse rechecks the client and finds the heart rate jumped from 88 to 126 with tremor and palpitations. The nurse reports to the RN, because these can be adverse effects of the bronchodilator that the provider should know about.
  2. Where questions turnAssuming a treatment worked and moving on without rechecking the client's actual response.
Practise this activity

22Reinforce teaching on procedures, treatments and equipment

  • Reinforce teaching the RN or provider began about a procedure, treatment or piece of equipment, in plain language the client understands.
  • Explain what to expect, how to prepare (such as fasting), and what the client should do and report afterward.
  • Teach equipment use by demonstration and return demonstration: an incentive spirometer, a glucometer, compression stockings or a new dressing.
  • Use the client's language with an interpreter when needed, and provide written or picture materials.
  • Have the client teach back the key points so you can confirm understanding and correct gaps.
  • Report questions beyond your scope or a need for new teaching to the RN or provider; the practical nurse reinforces rather than starting teaching on a new diagnosis.
  1. In practiceBefore discharge the practical nurse reinforces how to use a glucometer: has the client wash hands, load the strip, obtain a drop from the side of the finger, read the result and record it, then watches the client do it to confirm the technique.
  2. Where questions turnTelling a client how to use new equipment without a return demonstration, so a mistake goes unnoticed until home.
Practise this activity

Key terms

Urinary retention
The bladder does not empty; signs include a full, firm lower abdomen and small frequent voids.
Bladder scan
A noninvasive ultrasound that measures the volume of urine left in the bladder.
Critical value
A laboratory or point-of-care result dangerous enough to require prompt reporting.
Preeclampsia
A pregnancy disorder with high blood pressure, protein in the urine and symptoms such as headache and swelling.
Infiltration
IV fluid leaking into tissue; the site is cool, swollen and pale.
Phlebitis
Inflammation of a vein, often from an IV; the site is red, warm and tender along the vein.
Air embolism
Air entering the venous system, a risk with central lines; treated by clamping, left side head-down position and oxygen.
Neurovascular check
A circulation and nerve check of a limb: color, temperature, capillary refill, pulses, movement and sensation.
Glasgow Coma Scale
A scale that scores eye opening, verbal response and motor response to measure level of consciousness.
Sequential compression device
Inflatable leg sleeves that squeeze and release to help prevent deep vein thrombosis.
Clean-catch midstream urine
A urine sample collected after cleaning and starting the stream, to reduce contamination.
Hemolysis
Breakdown of red cells in a blood sample, which can give false results and require a redraw.

After this guide: After this guide you should be able to reduce a client's risk from conditions, tests and procedures as a practical nurse: take measurements and specimens correctly, care for tubes and lines within your scope, recognize an early complication and report what belongs to the RN or provider.

Practise Reduction of Risk Potential