SCORES
A patient is oriented and opens their eyes spontaneously, but only responds to pain by extending their arms and legs, what is their GCS score
4 Eye + 5 Verbal + 2 Motor =11
Methotrexate
Yellow Bin
How long after checking out blood from the blood bank do you have to initiate the unit
15 minutes
Dwell time of Purple wipes
2 Minutes
Verbal/telephone restraint orders can be accepted by the nurse and must be cosigned within
24 hours
Fall Risk Score: A 67y/o Male patient has a history of falls, uses a walker, takes numerous home meds (Digoxin, Warfarin, Meclizine) walks with an impaired gait, and forgets their limitations, lives alone after recent loss of spouse of 55 years
History of falls = Yes (4) + Polypharmacy=Yes (3) + CV Meds = Yes (3) + Age >65= Yes +(2) + Cognitive Deficit = Yes +(2) + Vertigo = Yes (2) + Depression = Yes (2) + Mobility Deficit = Yes + (2) + Male = Yes (1) = Total Score=21
Ketamine
RXDestroyer
A patient who has received multiple blood transfusions over the years develops fatigue, joint pain, and hepatosplenomegaly.
Iron overload (hemosiderosis)
Curos caps must be in place for how long or a port scrub is required
1 minute
When all four side rails used for a patient who CAN NOT PHYSICALLY get out of bed is _________ a restraint
NOT
RASS: The patient is restless and anxious but does not engage in any aggressive movements or actions.
+1 (Restless)
Potassium Tablet that fell on the floor
Blue Bin
Which part of the Blood Administration Record (Unit Information) doesn’t have to be verbalized?
Order#, Requested by, and Registration date and time
Mid Lines are required to be changed
96 Hours (4 days)
Violent restraint orders are limited to ____ hours for a 17-year-old.
2 Hours
GEMS SCORE: An 82-year-old patient who can walk independently, lives with a daughter, has well-managed chronic conditions (e.g., hypertension, arthritis), takes only one medication, and has a strong network of family and friends
Gait: 0 (walks independently)
Environment: 0 (lives with daughter and has social support)
Medical History: 0 (well-managed conditions)
Social Support: 0 (has strong support)
Medication: 0 (no polypharmacy)
Total Score = 0 (Low risk)
Nitroglycerin
Black Bin
Which reaction would manifest as respiratory distress, orthopnea (difficulty breathing when lying flat), and increased blood pressure. It is most commonly seen in patients with pre-existing heart conditions or those receiving large volumes of blood
Transfusion-Associated Circulatory Overload (TACO)
How many times can a Curos cap be re-applied
Never
Non-violent restraint orders are episodic and must be received at the time of or within ___ hour(s) of the initiation of the restraint/seclusion
1
Braden Score (pressure injury) A patient is completely unresponsive to any stimuli, is bedridden, has very inadequate nutrition, and experiences constant moisture and friction.
Sensory Perception: 1 (Completely unresponsive)
Moisture: 1 (Constantly moist)
Activity: 1 (Bedfast)
Mobility: 1 (Completely immobile)
Nutrition: 1 (Very inadequate)
Friction and Shear: 1 (Major problem)
Coumadin
Return to Pharmacy
This is a rare but serious transfusion reaction that is characterized by sudden onset of respiratory distress, hypoxemia, and acute pulmonary edema, usually occurring within 6 hours of the transfusion. It is caused by an immune reaction between the donor’s white blood cells and the recipient’s lungs.
Transfusion-Related Acute Lung Injury (TRALI)
A Foley must be replaced if it has been in place longer than ___ hours before collecting samples
48 hours
An immediate post-op patient returns with an ET Tube, Chest tube, Foley, FMS, and JP drain x2. Do you need an order for restraints
Yes, and defined as EPISODIC, it is applied as a protective intervention to support medical or surgical care.