Prioritization
A nurse receives report on four patients. Which represents an airway problem?
A patient with stridor and difficulty speaking (airway obstruction is the highest priority in ABCs)
What is the correct order for donning PPE?
Gown → Mask → Goggles → Gloves
Pain is considered the "_____ vital sign."
Fifth vital sign (per Joint Commission standards)
What are the "rights" of medication administration?
Right patient, drug, dose, route, time, documentation (some add: right reason, right to refuse, right assessment)
Which medication classes increase fall risk and by what mechanisms? Name at least three.
Sedatives, hypnotics, tranquilizers - decrease alertness and slow reaction time
Diuretics, antihypertensives, antihistamines - increase risk of orthostatic hypotension
Patient A has chest pain. Patient B has a bleeding laceration. Patient C needs pain medication. Who is first priority?
Patient A - chest pain threatens circulation (life-threatening per ABCs)
A patient has C. difficile. What hand hygiene method must you use?
Soap and water (alcohol doesn't kill C. diff spores)
A BP reading of 110/60 is obtained on a 70-year-old whose usual BP is 154/90. What should the nurse do?
Recognize this as LOW for this patient and assess further (know the patient's usual range, not just one measurement)
Before giving any medication, what must you check on the patient?
Two patient identifiers (name and date of birth or medical record number)
A confused patient keeps attempting to get out of bed unassisted. What must you try BEFORE applying a bed alarm or protective device?
Less restrictive techniques first (per legal and Joint Commission standards). Examples: implement toileting schedule, move patient closer to nurses' station, provide companionship/sitter, address underlying needs (pain, toileting, hunger).
A patient has RR 28, O₂ sat 88%, and is restless. What priority framework guides your immediate action?
ABCs - this is a breathing problem requiring immediate intervention
Which precaution requires an N95 respirator mask?
Airborne precautions (TB, measles, varicella)
What respiratory pattern describes difficult, labored breathing with flared nostrils and "I can't get enough air"?
Dyspnea
A medication order reads "digoxin 0.125 mg BID daily." What does BID mean?
Once in the AM and PM (twice a day)
Full side rails are raised on an alert, oriented 80-year-old to "prevent falls." What legal violation has occurred and why?
False imprisonment - full side rails are considered restraints because they limit the patient's ability to move. Evidence shows bed rails as restraints can be harmful. Half-rails for repositioning assistance are not restraints.
Which vital sign indicates the most urgent breathing problem: RR 22, RR 10, or RR 16?
RR 10 (bradypnea <12 indicates respiratory depression/failure)
What is the correct sequence for removing PPE?
Gloves → Goggles → Gown → Mask (most contaminated first)
When vital signs change significantly, what two actions must the nurse take?
Notify the primary care provider AND document the change with narrative entry including actions taken
When should you document medication administration?
Immediately after giving it (never before administration)
Where do most falls occur in older adults, and what assessment must the nurse perform related to these locations?
Bedroom and bathroom. Assess how the patient navigates these areas during ADLs. If cognitively impaired, implement a toileting schedule to discourage self-toileting and potential falls.
A patient is choking and cannot speak. What is your first action?
Attempt to clear the airway (Heimlich maneuver/back blows) - airway is always first priority
A patient has influenza. What type of precautions and what PPE?
Droplet precautions - surgical mask required (not N95)
A patient in the febrile stage of fever develops confusion and begins having involuntary muscle contractions. What two complications are likely occurring, and what physiological mechanism causes them?
Delirium and febrile seizures (convulsions)
What must you assess before administering opioid pain medication?
Respiratory rate, pain level, level of consciousness, and vital signs (opioids can cause respiratory depression)
What must be included in a fall risk assessment?
Evaluation of the patient's medications (correlated with increased fall risk), mobility, mental status, and environment