NCLEX Nursing Interventions- When and what to do.

Nursing Interventions in Emergencies

NO Provider Order Required

Think: Independent nursing actions + standing emergency protocols

🔴 AIRWAY (Always first)

LPN & RN

• Position patient to open airway (head-tilt chin-lift, jaw thrust if trauma)

• Suction oral or nasal secretions

• Insert OPA or NPA if trained and facility allows

• Apply oxygen (nasal cannula, non-rebreather)

• Encourage coughing and deep breathing

• Remove visible airway obstruction

• Call Rapid Response or Code Blue

💡 N-Clex Tip: Oxygen is a nursing intervention, not a medication.

🔴 BREATHING

LPN & RN

• Apply oxygen for hypoxia or respiratory distress

• Elevate head of bed

• Encourage incentive spirometry

• Assess breath sounds

• Monitor pulse oximetry

• Assist with bag-valve mask during codes

RN only

• Interpret ABGs

• Escalate ventilatory support concerns

🔴 CIRCULATION

LPN & RN

• Apply direct pressure to bleeding

• Elevate bleeding extremity

• Position patient supine for shock

• Initiate CPR

• Attach AED

• Monitor vital signs

• Assess pulses, cap refill, skin color

• Maintain IV patency if present

RN only

• Start IV access (facility dependent)

• Initiate rapid fluid bolus if protocol exists

🟠 NEURO / ACUTE CHANGE

LPN & RN

• Perform neuro checks

• Check blood glucose for altered mental status

• Implement seizure precautions

• Protect patient from injury during seizure

• Reorient confused patient

• Ensure safety restraints ONLY if policy allows

RN only

• NIH Stroke Scale

• Activate stroke alert

🟠 PAIN & DISTRESS

Independent (No order)

• Reposition

• Ice or heat (if appropriate)

• Splint injured extremity

• Calm environment

• Guided breathing

• Distraction techniques

💡 N-Clex Pearl: Always try non-pharm first unless pain is severe.

🟡 FLUID & ELECTROLYTE IMBALANCE

LPN & RN

• Strict intake and output

• Monitor urine output

• Daily weights

• Assess edema

• Assess skin turgor and mucous membranes

• Elevate legs for edema

RN only

• Interpret labs (Na, K, BUN, Cr)

• Initiate electrolyte replacement per protocol

🟡 INFECTION & SEPSIS PREVENTION

LPN & RN

• Hand hygiene

• Don PPE

• Isolate patient

• Monitor temperature

• Remove contaminated devices

• Encourage fluids

• Obtain cultures if ordered (RN often initiates)

💡 N-Clex: Isolation can be started before provider order if indicated.

🟢 SAFETY INTERVENTIONS

Independent

• Implement fall precautions

• Bed in low position

• Side rails up as appropriate

• Remove hazards

• Apply non-skid footwear

• Supervise confused or aggressive patient

🟢 PSYCHOSOCIAL EMERGENCIES

LPN & RN

• Therapeutic communication

• De-escalation techniques

• Maintain personal safety

• Stay with suicidal patient

• Remove harmful objects

• Initiate suicide precautions per policy

RN

• Full suicide risk assessment

• Initiate involuntary hold process per law

🧠 NGN CLINICAL JUDGMENT CONNECTION

When you see an emergency scenario, ask yourself:

1. What can I do RIGHT NOW?

2. Does this require a provider order?

3. Is this an airway, breathing, or circulation problem?

4. Can I make the patient safer immediately?

If yes → That’s your answer

🚨 TEST ALERT: WHAT NCLEX WANTS YOU TO PICK

• Oxygen

• Positioning

• Suctioning

• Pressure to bleeding

• Safety measures

• Rapid response activation

• Assessment before action

• Non-pharmacological interventions