Musculoskeletal/Wounds
When documenting a wound, what should you include?
§Location
Length (head to feet)
Width
Depth
Color
Undermining (clock method)
You are sending your patient home on oxygen, what is a major teaching point?
Fire risk, no smoking
When someone is constipated what medication would you anticipate being ordered?
Cathartics
What are normal vital sign ranges?
HR: 60-100
BP: 120/80 (less than 90/60 greater than 130/90 abnormal)
RR:10-20
O2- 94-100
T 97.8-100.4
When administering narcotics, what needs to be closely monitored?
Respiratory Status
When caring for patients in Bucks traction, how would you clean the pin sties?
sterile swab
*What is Bucks traction used for?
When assessing pain, what do you want to know?
Rating on scale, location, quality, frequency, time, causes
What are 3 ways you can obtain a urine specimen. How would you obtain each?
Clean catch- sanitize, middle of stream
Straight Cath- sterile procedure, catheter does not stay in
Foley- Side port, clean port with alcohol, never take from bag
*What needs to be on the label?
Where do you auscultate the apex of the heart (PMI)
5th intercostal space, midclavicular line
What are signs of infection when assessing a central line?
Erythema, pain, exudate/drainage, fever
Your patient is bedridden and incontinent. What are major concerns?
Skin integrity, monitoring I&O, falls
When caring for a chest tube, what are you assessing?
Site for infection, output, bubbling in chamber, suction or water seal settings
Why would a patient need a colostomy? How should the stoma look?
Bowel obstruction/perforation.
Clean, moist, red/pink
Your patient is receiving a blood transfusion. The patient complains of feeling hot, lower back pain, and is tachypneic. What do you do?
Stop transfusion, discard tubing, run NaCL, call provider.
*Save blood product and tubing for further investigation
How would you open a sterile field such as a Foley catheter?
Away from yourself, only touching edges, never reach over sterile field
Your patient has a cast on their upper extremity, what are you assessing for in this patient?
Pulse, temperature, pain, tingling sensation, color, capillary refill
You are teaching a patient's family member how to suction a trash. What are key teaching points?
Preoxygenation, sterility
What are fat soluble vitamins?
ADEK
(C, B, riboflavin, biotin, niacin are water soluble)
*Why do we care?
You notice dark red blood in the stool. What labs/tests would you want ordered?
occult fecal test
H&H
The unit secretary calls and says someone is on the phone looking for an update on the patient. They said they are a friend. Do you give them an update?
It depends. Are they listed in the patients chart as an emergency contact, is the patient alert or awake to give you permission?
What PPE do you need when irrigating a wound?
Glove, gown, mask, eye protection
*******
Standard precautions
Contact
Droplet
Airborne
What is the most common cause of respiratory demise?
Obstruction (secretions, narrowed airway, inflammation, OSA, aspiration)
How do we assess for NG placement?
pH strip
*How do we confirm placement after insertion?
You are listening to heart sounds, you know that which valves close with S1 and S2?
S1- mitral and tricuspid
S2-aortic and pulmonic
Where does the tip of a central line terminate?
Superior Vena Cava