Pressure injury prevention measures to take if a patient has a Braden scale of less than 18 (list at least 3)
What is turn at least every 2 hours, apply mepilex sacral dressing (if not incontinent), apply bilateral mepilex heel dressings, off load with z flex boots
How do you confirm placement of a small bore feeding tube?
What is an chest XRAY?
Your patient is reporting chest pain. What should be to be your first intervention?
What is get an EKG? An EKG needs to be done within 10 minutes of a patient reporting chest pain.
You have to perform a chest tube dressing change and need to refresh your skills on current best practice. Where would you go to find this information?
What is Lippincott and Policytech.
Your patient has new facial droop and is drooling, you activate inpatient stroke activation by dialing this number.
What is 7-7111
You are performing a BMAT assessment on a patient. They are able to stretch and point each leg/foot, but are unable to stand with good balance for 5 seconds. What BMAT level are they and what equipment might you use to mobilize them?
What is level 2. What is a sit to stand, hoyer lift, etc.
HIT is a rare reaction seen with which medication? A nurse might recognize this condition by trending what lab value.
What is Heparin and platelets.
If your patient were to fall, what 4 documentation items must be completed?
What are a Fall Debrief form, SafetyNet, objective nursing note, and Morse fall score reassessment.
ERAS principles state surgical patients need to do this within 4-6 hours of arriving on the unit.
What is ambulation (early ambulation). Ambulation after surgery helps patients breathe better, helps with digestion, and helps prevent blood clots.
When admitting a new patient to the floor, 2 people are required to do what?
What is 2 person skin check.
The provider orders a chest tube set up to continuous suction: 20cm. What does the wall suction need to be set to achieve this?
What is -80mmHg (on wall)
You're changing your patient's chest tube dressing and you feel crepitus around the insertion site. What does this mean? And what do you do?
What is air leaking into the subcutaneous tissue and notify the provider.
Current best practice guideline advises against collecting a urine specimen from a Foley catheter that has been in place for more than _______ due to the risk of bacterial colonization in the tubing and bag.
What is 2 midnights?
It's after 7 PM, where would I go to find out which specialty provider is on call for the night?
What is QGenda found on the MyIntermountain homepage?
What type of cleaning treatment is required for patients with a central line and how often must this be completed?
What is a daily full body CHG treatment after a hygiene bath.
List at least 4 neutropenic precaution interventions.
What are:
1. Place a neutropenic precaution sign on the door
2. Perform hand hygiene on entry to and exit from the room
3. Keep door closed
4. No visitors with any type of infection/illness allowed
5. No fresh flowers or plants
6. No pets
7. No fresh, unwashed/uncut fruits or veggies
8. The patient must wear a mask if leaving the room
Your patient came in with trauma with probable cervical injury. What medical equipment should be in place?
The X-Ray shows no fracture in the cervical spine. The family is wondering if we can remove the C-collar. What would be your response?
What is a cervical collar (c-collar)? Waiting for official C spine clearance from the provider before removal.
You just gave IV dilaudid to your patient and performed a pain assessment. Per policy, when do you need to perform a reassessment?
What is 15 minutes?
We need to include at least 3 of these in each of our care plans for the shift.
What are SMART goals.
These 2 procedures require 2 nurses be present to help ensure sterile procedure is maintained.
What are foley catheter insertion and central line dressing changes.
What vital sign is a key indicator of deterioration in sepsis? What is that compensating for?
What is increasing respiratory rate and metabolic acidosis.
Before administering blood products, it is crucial to perform this test to ensure compatibility between the donor and recipient.
What is crossmatching?
In terms of fire response, RACE stands for what?
What are Rescue, Alarm, Contain, Extinguish.
What are two common conditions that result in the production of lactic acid?
What is hypoxemia and ischemia?