Crash Cart/IV Pump
How do you activate a Code Blue or Medical/Pediatric Response Team?
Dial 200
When should a Foley Catheter or Central Line be removed?
As soon as possible to decrease the risk of infection
Name two less restrictive techniques that can be used to avoid having to use restraints.
Removal of Lines, Exercise, Distraction, Music Therapy, Prayer, Meditation, Family Visitation, etc.
If the chest tube dressing becomes soiled, the nursing staff member should do what?
Change the Dressing
When should a head-to-toe assessment of the skin be completed?
At minimum upon admission and each shift
On the IV Pump Infusion menu, which option should never be used because it does not have guardrails?
Basic Infusion
How often is the need for a foley catheter or central line assessed and documented?
Each Shift
How many Patient Room Self-Harm Prevention Checklist should you complete per shift?
Two: One at each shift change with off going or on coming nurse
Where is the hook up for wall suction on both drainage systems?
When measuring the length & width of a wound, how should the measuring guide be placed?
Length: Vertically Head to Toe (12 o’clock and 6 o’clock) at the area of greatest length
Width: Horizontally (3 o’clock and 9 o’clock) at the area of greatest width
What color is the zip tie that is used to secure the crash cart after a code? And where on the crash cart will you find it?
Yellow and Under the Medication Tray
How long do you scrub the hub?
15 seconds
How often does the patient need to be assessed and monitored when restrained for non-violent behavior?
Every 2 Hours
Where should the chest tube drainage system be placed?
On the floor or hung on the bed below the level of the heart. Be sure to avoid creating dependent loops, kinks, or pressure on the tub.
If a patient has a dressing upon admission, what should you do?
Take the dressing off and assess the wound and document. Contact provider for dressing change order and/or implement protocol order. Consider wound nurse assessment.
If the G icon is displayed on your pump what does it mean?
The infusion is running outside the safety guardrails.
How often is a transparent CVL dressing changed? How often should a CVL dressing with gauze be changed?
Transparent: 7 days
Gauze: 48 Hours
How often does the patient need to be assessed and monitored when restrained for violent self-destructive behavior?
Every 15 Minutes
The nursing staff member should monitor what in the chest tube drainage collection chamber and notify the provider of any sudden changes?
Color, Consistency, Amount
How do you measure depth?
Use a linear device such as a cotton tipped applicator. Gently insert the device into the deepest area of the wound (keeping the device at 90degrees. Use your thumb and index finger to grasp the device where it exit the wound at skin level then using a measuring device measure from the tip of the device to the point on the device where your thumb and index are.
What is the Five Overall Functions of the Debribrillator?
Monitor, Pace, Defibrillate, Synchronized Cardioversion, AED Mode
What information should be placed on the Communication Board if your patient has a Foley Catheter? Central Line?
Foley Catheter: Insertion Date & Last Hibiclens Date
Central Line: Insertion Date, Last Dressing Change, Last Caps Change, Last Hibiclens Date
If a patient self-harms or attempt to self-harm, what steps should you take?
1. Ensure patient safety, perform assessment, and document findings
2. Notify patient care team, patient healthcare POA, and leadership. Document notifications
3. Complete Post-Self Harm Huddle
4. Complete Incident Report
What is tidaling? Is it normal? When does it occur?
Normal fluctuation in bubbling. It is normal and occurs during respirations.
Documentation of a wound should include what?
Drainage Type & Amount
Wound Bed Color
Location
Measurement (upon Admission)