MEET MAYHEM
Three letter acronym often used to prioritize patients
ABC
ADPIE
Assessment
Diagnosis
Planning
Intervention
Evaluating
Normal color of a tympanic membrane.
pearly gray
Which is an unexpected finding?
a) Blood in urine post TURP.
b) HR goes below 50 while sleeping > 74 if awake
c) Wheezing heard during an asthma attack
d) IV site burning while pushing Magnesium
b) HR rate should not drop that much in the average person
Management of care starts where/when?
At bedside report
Joey is 8 years old and fell while on his skateboard. You notice bruising behind his ear. What is this called?
Battle's sign = basil skull fracture.
Name three components of the Physiological stage of Maslow's Hierarchy of Needs
breathing
food
excretion
sleep
homeostasis
Another name for nearsightedness
Myopia
You arrived on seen of an MVC, who to label with Red tag?
a) Man with abrasions on face and bil upper arms
b) Woman with dislocated shoulder
c) Woman who hit head now doesn't know name.
c) Woman with head trauma and symptomatic of mental status changes.
Nurse Greg's tech reports a patient's BP of 156/98.
What should Nurse Greg do?
Check the chart to see if this is trending up or down from before.
Type of hyperthermia characterized by inability to produce sweat.
Heat stroke
This is Nurse Nancy,
I'm calling about Joe Smoe in room 115 admitted this morning for pneumonia. His date of birth is 11/10/1991. He is currently sating at 90% on RA and working hard to breathe. His respirations are up to 24 and he is getting anxious.
What is missing from this SBAR call?
Recommendation
What do you want from the provider?
Type of hearing loss that blocks sound waves before they reach the cochlea of the inner ear?
Conductive
Who to assign to the LPN, patient with...
a) COPD sating 91% (came in at 89%)
b) order for PRBCs 2 units STAT
c) Lab orders to draw from Central Line
d) DC patient needing instructions post mastectomy
a) patient is stable
d is stable but LPN can not give initial instructions can only reinforce instructions already given by RN
Darcy is a SRNA assigned to you as a tech on your shift today. You know Darcy is also a nursing student at BCTC. Darcy asks if she can put in your patient's Foley. What will you say.
NO
Darcy is working in the capacity of a tech and therefore cannot perform nursing duties.
# of years recommended to have a tetanus shot as an adult after all series are completed?
Every 10 years
Who do you see first?
a) President of the hospital in for a cystoscopy.
b) Homeless man with COPD with O2 sat of 92%.
c) Farmer with a large laceration to his thigh with lots of blood.
d) Businessman who is pasty looking and c/o not feeling right with a BP of 88/40.
Business man is highest risk of death.
Which is a medical emergency?
a) Astigmatism
b) Anisocoria
c) Retinal detachment
d) Strabismus
Retinal Detachment
What ESI level is 3 or below?
a) VS: 210/110-133-24-98.9-94%
b) VS: 158/99-120-22-99.6-92%
c) VS: 100/66-72-20-96.6-96%
d) VS: 99/50-120-24-96.4-91%
c) VSS
Assessment, Analysis, Planning, Implementation, and Evaluation are parts of the nursing process but also a part of this judgement model.
Name this two word module
Clinical Reasoning
#1 Nursing priority to prevent further damage of a broken limb.
Immobilize the limb as it is.
Who to see first?
a) 20 yo with right lower abdominal pain with vomiting
b) 63 yo with severe knee pain who can't walk
c) 28yo 38wk pregnant with irregular contractions 6-15 min apart
d) 45yo whos ride is downstairs awaiting DC instructions
a) Potential appendicitis with possible rupture.
Difference between Glaucoma and Cataract?
Glaucoma is a pressure injury causing tunnel vision and halos around lights
Cataract is a clouding of the lens of the eye and makes it appear as though the person is looking through a fogged glass.
What order will you see these patients on site?
a)34yo with 2nd degree burns bil arms
b)65yo with crushed jaw that appears dislocated
c) 40yo with bil amputations lower limbs
d)29yo c/o difficulty breathing and pain in back
1. b
2. d
3. a
4. c
You attend a nurse unit meeting and withness that John made some great suggestions that were shot down because he is a new nurse. You have more great ideas but are afraid to express them. What type of safety breach is this?
Psychological Safety