Lines & Drains
Does the RN need an order to remove the Foley?
Yes, but the order may be per algorithm or ???
This infusion drip inhibits the production of blood clots (stops clots from forming or growing)
Heparin
This is the single most effective way to prevent the spread of healthcare-associated infections.
What is hand hygiene?
When is Milking and Stripping of chest tube done by the RN?
Never: because it can cause increased intrathoracic pressure
This is what CAUTI Policy States regarding when to empty the foley.
What CAUTI Policy States:
This drug dissolves blood clots (by breaking down fibrin)
Alteplase
This device-associated infection can be reduced by removing the device as soon as it is no longer needed and maintaining a closed drainage system.
What is a CAUTI (Catheter-Associated Urinary Tract Infection)?
This is the maximum number of days a Huber needles is allowed to stay in the port before needing to be changed.
What is 7 days
These two lab tests determine if patient is withing therapeutic range of Continous IV Heparin Administration
PTT or anti-Xa
Elevating the head of the bed 30-45 degrees and performing daily oral care are key interventions to prevent this infection.
What is VAP (Ventilator-Associated Pneumonia)?
A nurse calls the provider- patient blood pressure has dropped from 128/76 to 86/50, HR has increased to 124. The nurse explains that the patient “just doesn't look right.”
Which essential SBAR element(s) is missing?
What is Recommendation — the nurse should clearly state the urgency of the situation and request immediate evaluation and specific next steps from the provider?
If background included that is also correct but not as stand alone answer.
A nurse is setting up a Pleur-Evac chest drain. They add water to the suction control chamber through its yellow covered opening but forgets a second step involving the tubing that will later connect to wall suction.
What additional step must the nurse complete to ensure the water seal chamber functions properly?
What is use the funnel to add water through the suction tubing's designated fill pathway, and ensure the water seal chamber is filled.
A patient receiving continuous IV heparin infusion has labs ordered every 6 hours. According to medical orders, when may the lab monitoring schedule be changed to every 24 hours?
What is after two consecutive lab results are within the therapeutic range?
The central line maintenance practice of scrubbing the hub before access and performing daily necessity reviews reduces the risk of this.
What is CLABSI (Central Line-Associated Bloodstream Infection)?
This is considered insulin stacking or "overcorrecting."
What is Administering repeated correction doses of rapid-acting insulin before the previous correction dose has finished working.
Note: nutritional doses do not carry the same risk because the patient ate.
PTT tells me how long it takes blood to clot; this test tells me how much heparin activity is actually present.
What is Anti-Xa?
A patient develops diarrhea after receiving multiple antibiotics. Contact precautions and handwashing with soap and water are recommended for this organism.
Question: What is Clostridioides difficile (C. diff)?
The nurse is assessing a new post-op admit and notices increasing temperature, tachycardia, and the patient is having masseter spasms. These signs and symptoms indicate which general anesthesia emergency?
What is Malignant Hyperthermia?