5 and 2 is coming for you!
If a patient preferred language is not English what needs to be documented?
The use of a interpreter with services name and number. Only certified interpreters can translate.
Screenings questions in secondary triage are optional
False, many of these are state mandated. Psychosocial, abuse/neglect and exploitation and falls risk need to be assessed on any patient.
For trauma patients what do we need to check along with vital signs q 15 x 2 hr then hourly until disposition?
GCS
The environmental safety checklist needs to be completed how often?
q shift and with any room or sitter change. A shift is defined as q 8 hr
If a patient mistakenly registers they can be dismissed from epic under what term?
Erroneous
I've fallen and I can't get up... hip, shortened and externally rotated ..what do I need to document
...hipfracture
Hip Fx booklet
An adult assessment needs to be documented how often?
On arrival and once a shift
This needs to be completed after every full activation to identify opportunities in care
What is the full activation huddle
What nurse driven assessment needs to be completed for all patients who are withdrawing from alcohol ?
BAWS assessment
What needs to be documented prior to administering any PO to a patient with a suspected stroke?
yale dysphagia screen
If I am unable to reach the trauma provider or am concerned with a residents care what do I use to escalate my concern?
The trauma escalation guideline
DAILY DOUBLE! 2 QUESTIONS
How many sets of vitals are due when sepsis fluids are completed?
Can a repeat lactic wait until sepsis fluids are completed?
2 SETS OF BP'S ARE NEEDED WITHIN THE OUR OF FLUID COMPLETION .
NEVER!! IF ITS DUE.... DRAW IT ..WE ARE EVALUATING OUR INTERVENTIONS AND TREND
VAD settings along with vitals have to be documented how often ?
Q 4 hours
What order needs to be entered along with violent restraint order?
1:1 observation
In a patient who has an open fracture what has to be given in what time frame to reduce infection?
Antibiotics within 60 minutes from the door
What documentation is required after a fall?
Notify provider
Post fall assessment - (In flowsheet)
Post fall huddle form on paper
One link
What flowsheet needs to be used for Code Stroke patients?
The stroke care intervention flowsheet
Daily Double Question
How often do vitals need to be completed during conscious sedation intra and post procedure?
If you give a reversal medication , how much longer do we need to monitor?
q 5 min intra, q 15 min post
q 15 min for an additional 90 minutes
What needs to be completed q 4 hours when you have a patient that requires a safety companion?
Patient safety companion assessment
What do you do for a patient who comes into the ED with a foley?
What do you have to do if the patient has a ua/urine culture order?
Document the foley along with a POA order.
Obtain an order to change the foley and collect a UA/urine culture from the new foley.
How long after glucometer disinfection with a bleach wipe , does it need to dry before docking or performing another glucose check?
4 minutes
How long do you have to documentation wound and where does this documentation go?
8 Hours and it gets documented in a nursing note or under LDAW
How do you mix an epi gtt? What is the concentration?
1-2mg / 250 ml NS
What assessment needs to be completed on patients over the age of 65 with an ESI of 1,2, and 3? (HINT it comes up in the secondary triage)
DTS screening
What do you order for a patient 35 years or older with any chest pain or atypical chest pain related complaints?
How long do you have to get the above completed?
Chest pain protocol
10 minutes