Blood Transfusion
Code Response
Restraints/Suicide Risk/ Observation Levels
Infection Control
Stroke
100
The first thing to do when there is a suspected blood transfusion reaction
stop the infusion
100
When would you call a code 101c?
The patient has no pulse and/or no breathing (aka cardiac arrest or respiratory arrest).
100
When are mittens considered restraints?
If the mittens are tied to the frame of the bed.
100
What is the most important thing you can do to prevent transmission of infection.
Wash your hands regularly with soap and water
100
What does the acronym BEFAST stand for
Balance, eyes, face, arms, speech, and time
200
The only solution that is compatible with blood is:
Normal saline (0.9% NS)
200
You see this rhythm on the cardiac monitor and the patient has no pulse. What should you do?
Start high quality CPR and call for help.
200
What document tool is used at FHMC to assess for suicide?
CSSR-S
200
How often do you change IV sets for TPN or fat emulations?
24 hours
200
Before TNK is given the BP must be below ____ mmHg
185/110
300
Blood product administration must begin within ______ minutes from the time the blood product leaves the Blood Bank
30
300
Why is the purpose of debriefing after a Rapid Response?
To identify areas for improvement in communication, teamwork, and clinical decision making, and enhance patient safety.
300
When do you perform suicide risk?
First point of contact for entry to the hospital
Upon admission to inpatient areas
Upon transfer in level of service e.g. psychiatry to medicine, medicine to psychiatry
For low and high risk patients, daily and on day of discharge.
At any time if staff becomes concerned by emotional or behavioral disturbances exhibited by the patient.
300
Femoral lines should be removed after ___ hours
24
300
In permissive hypertension post acute stroke, what is the best practice on blood pressure range.
Best practice BP management recommends cautious reduction in BP to >220/120 mmHg (by no more than 20%) over the first 24 hours.
400
What information must you cross check when picking up blood?
- Patient Name
- Date of Birth
- Medical Record #
- Unit # (donation id. #)
- Expiration Date
- Blood Type and Rh of pt. and donor
400
You see this rhythm on the cardiac monitor, the patient is complaining of dizziness and fatigue. What medication do you anticipate to be given to this patient and how often?
Atropine 1 mg IV every 3 to 5 minutes for a maximum dose of 3 mg.
400
Is this statement true or false?
You must obtain doctors order before applying restraints
False. A nurse can apply restraints first, then obtain a doctors order immediately after.
400
What is the correct order of PPE for donning and doffing in a COVID isolation room?
Donning PPE: Gown, mask/respirator, googles/face shield, gloves
Doffing PPE: Gloves, goggles/face shield, gown, mask/respiratory, hand hygiene after removing all PPE
400
After 24 hours of administration of TNK, a significant hemorrhage was found on the CT scan of head. What medication do you anticipate will be given to this patient.
Cryoprecipitate and or antifibrinolytics
500
A patient is a PMH of CHF is receiving a blood transfusion. They suddenly become short of breath. What are your next steps?
1. Stop the transfusion
2. Place patient in upright position
3.Monitor V/S and give supplemental oxygen if needed
4. Notify physician
5. If ordered, administer any diuretics
For patients on volume restriction where a unit of blood cannot be infused in a timely manner coordinate with the Blood Bank to divide the unit into two aliquots to prevent transfusion-associated circulatory overload (TACO).
500
Which patient would you use synchronized cardioversion for?
For hemodynamically unstable patients with arrhythmias such as SVT, atrial fibrillation, atrial flutter, and ventricular tachycardia with a pulse.
500
Name the two types of restraints used at Flushing hospital
1. Mechanical Restraints: Soft limb holders, and 4 side rails are the only mechanical restraints in use at JHMC and FHMC.
2. Manual Restraints: Any manual or physical method that restricts the patient’s movement or normal access to his/her body. Manual restraint includes physical interventions that are designed to involuntarily hold or pin the patient to restrict movement that a patient cannot easily remove a grasp during escort or a “takedown” to the floor.
500
What is lesions of the lung causing exudate and necrosis, productive cough, may be accompanied by weight loss, anorexia, fever, chills, malaise, night sweats and fatigue?
Clinical manifestations of TB
500
What do you do when a patient develops stroke symptoms in the inpatient area?
1. Activate code 66
2. Determine patient last known well
3. Perform a fingerstick and obtain VS
4. Place patient on cardiac monitor
5. Ensure that patient has a large bore IV
6. Prepare patient for imaging