Medications
What do you do if the ordered medication and the available medication are totally different?
Do not administer, clarify order with doctor
Name 2 adventitious breath sounds
Wheezing, crackles, Rhonchi, Stridor, Rub
Name 3 ways to promote wound healing and skin integrity
Keep skin clean and dry
Monitor patient’s continence status and minimize exposure of skin impairment site and other areas to moisture from incontinence, perspiration, or wound drainage
Encourage adequate nutrition and hydration, get dietician involved if necessary
Maintain head of the bed at 30 degrees or less unless patient is on feeds
Encourage patient to change positions often, encourage ambulation if pt can and if pt cannot move self turn every 2 hours
Use pillows to alleviate pressure under bony prominences ie. sacrum, heels
Use appropriate skin care products
ie. barrier cream after incontinence
Febrile
PO
What angle do you administer IM injections
90 degrees
What is the normal capillary refill and how do you assess it
3 seconds of less
Nurse compresses the nail bed until it turns white and records the time taken for the colour to return to the nail bed
Greater than 3 seconds indicates some form of circulatory insufficiency
Name 3 interventions for fall risk prevention
Keep bed at lowest setting
minimize amount of lines (etc. o2, ivs, ecg leads)
patient education***
Sputum
Mucus/phlegm from your lungs
BID
Twice a day
Name 3 things you are looking for in your GFHP Skin Assessment
Skin Intact? Reddened? Breakdown?Bruising? (location/stage/size) Braden Scale? Risk factors
Wound Care/Drains: Location? Chronic/ulcer/skin breakdown-size/drainage/colour-describe dressing
Drains: type? Location? Drainage: amt/colour
Wound care provided? (describe dressing)
Dyspnea
shortness of breath
PR
Rectally
Name 3 things you are looking for in your Elimination Pattern part of your GFHP assessment
Abdominal Assessment: Soft? Firm? Tender?
Distended?Colour/ hernias/ Scars? Bowel sounds x 4? (active? Amt/min) Any nausea/vomiting?
Bowel Elimination: Last BM? Frequency?
Stool colour/amt/ consistency (soft/formed/hard/loose) On any medications to assist with? Continence?
Bladder Elimination: Continence? Voiding?
I & 0? (loss of other fluids as well)
Urine colour/odour/amount/
Catheter: type & size; patent? Catheter care?
I & 0 catheterization: frequency; amount; residual
Creatinine level: BUN: Na+ K+ Cl-
Dysphagia
Difficulty swallowing
Activities as tolerated
Name 3 Fall Risk Factors
Age; sensory changes (vision/hearing/balance/sensation)
Sedation; analgesics; weak; ¯Hb, ¯BP?
Diaphoresis
Excessive sweating
QHS
Every night/at bedtime