Procedures and Complications — NCLEX-PN

An EKG (electrocardiogram) records the heart’s electrical activity over time, revealing rate, rhythm, and signs of ischemia or infarction. Recognize the lethal rhythms — ventricular fibrillation, pulseless ventricular tachycardia, asystole, and pulseless electrical activity — which require immediate response. Always correlate the rhythm on the screen with the client’s actual pulse and level of consciousness before acting.

A biopsy removes a sample of tissue for diagnostic examination, often to confirm or rule out cancer. Verify coagulation status and signed consent before any invasive biopsy, since bleeding is the chief risk. After a liver biopsy, position the client on the right side to apply pressure to the highly vascular site and reduce bleeding.

Endoscopy uses a flexible scope to directly visualize internal structures such as the GI tract, often with biopsy or treatment during the same procedure. Because the throat is anesthetized for an upper endoscopy, withhold food and fluids until the gag reflex returns to prevent aspiration. Afterward, monitor for bleeding, signs of perforation (severe pain, fever), and the lingering effects of sedation.

Drainage is fluid that escapes from a wound, tube, or catheter, and its character tells you a great deal about healing. Describe it by color, amount, consistency, and odor — serous drainage is clear, while sanguineous is bloody — and report sudden bright-red or large-volume output. Track drain output every shift, since both a sudden increase and a sudden decrease warrant notification.

Bleeding is excessive internal or external blood loss that can quickly progress to hypovolemic shock. Rising heart rate with a falling blood pressure signals hemorrhage, so check the dressing and also look underneath the client, where blood pools by gravity. Apply direct pressure, notify the RN, and anticipate IV fluid resuscitation and possible transfusion.

A dressing is a sterile or clean covering applied over a wound to protect it, absorb drainage, and support healing. Change wet, soiled, or non-occlusive dressings promptly, and document the wound’s appearance, size, and drainage with each change. Match the dressing type to the wound — for example, maintaining a moist environment for a clean granulating wound to promote healing.

Infection is the invasion and multiplication of microorganisms in body tissue, triggering a local and sometimes systemic response. The cardinal signs are redness, warmth, swelling, pain, and drainage at the site, with fever and an elevated white blood cell count systemically. Older adults may not mount a fever, so new confusion or functional decline can be the only sign of infection.