Venous Access
How often do we change dressings on venous access devices?
Every seven days and whenever:
- dressing is no longer occlusive
-old blood is present
- pressure dressing is present
Your patient has a red, non-blanchable area to the coccyx. The doctor has put in a wound consult – do you think this is necessary?
No. A wound consult is not necessary for Stage 1 or Stage 2 pressure injuries (except in rare circumstances). The doctor can d/c this wound consult and this Stage 1 can be managed by floor nursing.
What are PINCH meds? (name the classes)
PINCH meds are high risk medications.
Potassium (concentrated electrolytes)
Insulin (IV insulin & U-500)
Narcotics and other potentially sedating medication
Chemotherapy
Heparin agents (all anticoagulants)
Where is the panic button located on the 7 Stoneman?
To the right of the UCO desk underneath the counter. You PULL it (not push)
List four non-pharmacologic methods of pain management
What must be included on the label on a bag of IV fluid?
-patient's name
- medical record number
- date and time bag was spiked
(for medications, also include medication name and dose)
Name 3 alternatives to an indwelling urinary catheter (IUC)
1. intermittent straight catheterization
2. condom catheters
3. external female catheters
4. urinals, bedpans, commodes
5. incontinence pads/chux
6. daily weights
When should pain be reassessed in eFlowsheets after administering 2mg IV Morphine to a patient?
Consider the onset of action. IV medications should be reassessed in 15 minutes.
Pain should be reassessed within 1 hour of administration of PO medications
A visitor falls at the nursing station. What type of emergency do you call and what is the number?
First Aid Response at 2-1212
Your patient is requesting a break from her pneumo boots. What is the maximum amount of time that a patient should have pneumo boots off for?
30 minutes
What is the maximum amount of time that a peripheral IV that was placed in an ambulance on the way to the hospital can stay in place?
24 hours
A patient is admitted with a 1.5 cm round wound on the back of their heel. The wound is superficial and the wound bed is pink with yellow slough covering half of it. What would you stage it as?
Unstageable
How do you know that your PCA lockbox has been checked by clinical engineering and deemed safe for use?
There should be a green dot sticker in the upper left or right hand corner of the back panel of the interior of plastic lockbox.
What is the preferred type of venous access in a Code Blue?
1. peripheral IV
2. intraosseous (IO)
a very distant #3? Central line
Your patient that you have assessed as a special stream fall risk tells you that she needs some extra time on the toilet and she will call for help when she is ready. Should you allow this patient time alone and let her call when she is ready?
No, you must remain within arm’s reach of any patient on special stream fall precautions when toileting.
You cannot get flush or get blood return from your patient's PICC. The physician writes an order for alteplase (tPA). Who should instill this medication?
IV RN for complete occlusion (can't flush or get blood return)
[Staff RN (with assistance if needed) for partial occlusion (able to flush, can't get blood return)]
How often should the dressing on a nephrostomy tube insertion site be changed?
every 24 hours until evidence of granulation tissue and healing
every 72 hours after evidence of granulation tissue and healing
Your patient is admitted to the urology service and is ordered for an oral chemo regimen - what must be done prior to administering this medication?
1. For initial order verification or any change in dosage, two chemo-competent nurses are required to verify the signed order. (You may call 11R or 7F for assistance with this).
2. Confirm the patient has consent for administration of oral chemo.
Name 2 places on 7 Stoneman where you could hide during a Code Silver event?
1. Med room
2. Clean Utility
3. Soiled Utility
4. Patient room
When taking information about a critical lab value, what 4 pieces of information do you need to ‘write down and read back’?
patient name
MRN
test name
result
Your patient has a PICC line, what must you assess prior to using?
Correct order for line
X-ray confirming confirmation
Order for “okay to use”
What type of PICC – power? Non-power? Heparin dependent? Non-heparin dependent? Single lumen? Double lumen?
How does site look – is dressing c/d/i? Dressing change protocol followed?
A foley catheter is only required for patients’ with an epidural if the epidural is at the level of ____ or lower?
T10 or lower
Any multi dose vial of medication (ie insulin) should be dated with an expiration date of ____ days from when initially opened?
28 days
(or the manufacturer's expiration date - whichever comes first!)
Name 3 signs of stroke and how a Stroke Stat is initiated.
Facial Droop
Arm weakeness or numbness
Slurred speech or inability to speak
Trigger patient, HO can make determination to call Stroke STAT, call 21212
How often must restraints be reordered?
How often must you document an assessment of a patient in restraints?
Reorder:
1. Violent restraints - q 4 hours
2. Non-violent restraints - q 24 hours
Assessment:
1. Violent - q 15 min (RN/Observer); q 2 hours RN
2. Non-violent - q 2 hours