Falls
Cardiac
Respiratory
Wounds
Miscellaneous
Endocrine
100
This is the most important first step in preventing falls when a patient arrives on the unit.
What is an accurate fall-risk assessment? Hester Davis
100
Before increasing the rate of this medication, a provider order must be obtained.
What is Cardizem?
100
This intervention should be initiated FIRST for a patient with SpO₂ 86% and signs of distress
What is apply oxygen?
100
Stage 2
100
A nurse needs to verify the hospital’s escalation protocol when a patient shows signs of clinical deterioration (e.g., rapid response activation criteria).
What is PolicyTech?
100
A blood glucose level below this value is generally considered hypoglycemia and requires intervention.
What is less than 70 mg/dL?
200
Who is responsible for ensuring fall interventions are in place everytime they enter the room?
Who is everyone?
200
This is the priority assessment before administering medications that lower heart rate, such as beta blockers or calcium channel blockers.
What is checking heart rate and blood pressure?
200
This oxygen device delivers 1–6 L/min and is typically used for stable patients with mild hypoxia.
What is a nasal canula
200
This type of pressure injury cannot be staged because the wound base is covered with slough or eschar
What is an unstageable wound?
200
A nurse wants step-by-step guidance on performing a central line dressing change using evidence-based practice.
What is Lipinncott?
200
After treating hypoglycemia, blood glucose should be rechecked after this amount of time to evaluate response.
What is 15 mintues?
300
This proactive practice involves checking on patients at regular intervals to address pain, positioning, toileting, possessions, and safety needs before problems occur
What is hourly rounding?
300
These lab values are especially important to monitor in cardiac patients because abnormal levels can trigger arrhythmias.
What is calcium, magnesium or potassium?
300
When a patient leans forward and braces their arms to breathe easier, they are using this classic positioning
What is the tripod position?
300
This is the most important action to take within the first 24 hours of admission related to pressure injuries
Complete skin assessment with documentation and staging
300
A nurse is unsure whether a medication can be crushed and administered via feeding tube—this resource provides reliable medication administration guidance.
What is Lexicomp, Micromedex, or Dynamedex?
300
A patient is very thirsty, urinating frequently, and has warm, dry skin—this condition is most likely occurring.
What is hyperglycemia?
400
A patient attempts to get out of bed unassisted—this missing bundle intervention could have helped prevent the fall.
What is a bed alarm?
400
This lethal rhythm presents as chaotic, irregular waves with no identifiable QRS complexes and requires immediate defibrillation.
What is ventricular fibrillation?
400
This emergency device is used to manually deliver breaths when a patient is not breathing adequately or at all.
What is a bag-valve mask (BVM)?
400
This occurs when the skin stays in place but underlying tissue shifts, commonly seen when a patient slides down in bed.
What is shearing?
400
A nurse is unsure how to troubleshoot a chest tube system and maintain proper water seal function—this resource provides step-by-step clinical guidance.
What is Lipinncott or (ICU nurse)?
400
A patient is sweaty, shaky, and complaining of hunger—this condition should be suspected first.
What is hypoglycemia?
500
A nurse identifies that a patient's Hester Davis Fall risk score increased during the shift due to new narcotic medications and frequent toileting needs. The nurse updates the care plan, initiates a bed exit alarm, and increases surveillance. This nursing process step is being demonstrated to prevent a fall before it occurs.
What is reassessment and modification of the fall prevention plan?
500
When unsure about how to safely administer a medication like Cardizem, this is the BEST place for a nurse to find accurate, trusted information.
What is the hospital-approved medication resource (e.g., Lexicomp, Micromedex, IV med guidelines or your facility policy/protocol)?
500
Before placing a non-rebreather mask on a patient, this part of the device should be partially inflated to ensure proper oxygen delivery.
What is a resevoir bag?
500
Full-thickness skin loss with visible adipose tissue and possible tunneling, but no exposed bone or muscle, is classified as this stage.
What is a Stage 3?
500
A postoperative patient is 12 hours after abdominal surgery. Their blood pressure has dropped from 128/78 to 92/58, heart rate increased from 82 to 118, urine output is 15 mL/hour for the last 2 hours, and they report increasing abdominal pain despite pain medication. Oxygen saturation remains 96% on room air. What is the nurse's priority concern?
What is internal hemorrhage (or hypovolemic shock from postoperative bleeding)?
500
The patient has 2 consecutive blood sugars greater than 180, what is the next step
What is notify the provider?