When a blood transfusion reaction occurs the nurse should
Stop the infusion
Start 0.9% Normal Saline
Collect a specimen
Send the blood to the laboratory/blood bank
What should the nurse do when a client has stated he is leaving the hospital because there is nothing wrong with him
Document what happened
Explain the risks involved in leaving
Ask the client to sign a form relinquishing the hospital
When the RN delegates to the LVN/LPN, what guides the principles of delegation
The Nurse Practice Act
Gather data about the nurse's performance and attendance history
What is HICS (Hospital Incident Command System)?
Unexpected patient movements when moving patients can cause
back injuries
What is it considered when a UAP scolds a client for missing the urinal and threatens to put a diaper on the client if it happens again.
Assault
What should the nurse consider when delegating to a UAP
The UAP's level of experience
A leader that has to initiate disciplinary action with an employee should follow
the institution's formal reporting processes
Give an example of patient that would be tagged red in a mass casualty disaster.
> 30 resp
< 10 resp
can be saved
when repositioning airway can save patient
When sentinel events occur and the organization studies what happened to prevent errors in the future, the organization is considered to have a
Culture of safety
Staffing vs Scheduling
staffing put the right person in the right position
A nurse delegates a task to an LVN and later discovers that task is not complete. What should the nurse do
Verify the LVN knows how to perform the task
When making change and protecting psychological safety, leaders provide opportunities for
What actions could be used to demonstrate client advocacy by a nurse?
encouraging verbalization of questions
calling HCP for needs unique to the patient
What would be the first actions in possible exposure to toxins, bioterrorism in the emergency department?
safety of the client, containing, decontaminating
What are the rights of delegation?
right task, right circumstance, right person, right direction or communication, right supervision/evaluation
A UAP refuses to perform an assigned task. What should the nurse do?
makes plans and decisions with the team
Aggressive versus assertive communicators
aggressive communicators are often controlling, interrupt often, tend to lay blame elsewhere, express their personal opinions, do not care about how their message is perceived, do not advocate for others rights
Quality improvement and benchmarking is based on...
comparing the organizations performance with that of the best-performing organizations
What are some examples of nonverbal communication? What would be perceived as positive information and what would be perceived as negative information?
eye rolling, nodding head, standing when an important speaker or announcement is taking place, shaking head, showing your hands, smiling
During an emergent situation, what should the nurse delegate to an LVN?
Task requiring a certain skill that the LVN is allowed to do with the LVN scope of practice
example: can give medications that are ordered for stable patients
Leaders can communicate a vision for the future through
involving others and connecting daily work to the vision
Incident Report should include:
client's name, hospital number, date, time, location, factual description of event, any witnesses, corrective actions, missed med-time it was supposed to be given, any client data (vital signs etc)