You are Smart
The client's BP dropped from 128/80 to 88/54, which SBAR component is this?
Assessment
A nurse performs an assessment immediately after a client reports chest pain. What type of assessment is being completed?
Focused assessment
You have 4 patients. Who has the highest priority per Maslows?
1. an anxious client
2. client that is feeling down about diagnosis
3. a client reporting difficult breathing
A client reporting difficulty breathing. Maslows prioritizes physiological needs first.
Glucose of 68, pain 6/10, scheduled for dc in 1 hour, wound care... who do you see first
glucose of 68
A PN is caring for a client admitted with SOB. Which action is part of the assessment phase of the nursing process? a. administer oxygen b. teach client to relax c. auscultate d. develop goals
Auscultate
Your little lady needs 40% oxygen. What type of oxygen delivery mask are you gonna put on her?
The Venturi
Early Sign of Hypoxia
Restlessness, anxiety, tachy (RAT)
A RN just asked you to go do the initial assessment on the new admit. What do you tell her?
I'm sorry RN Jackie (lol), I will be happy to reassess the patient later. You will need to complete the initial assessment on your new admit.
give me another name for abnormal lung sounds
adventitious....
Your lovely patient has the TB. How are you gonna proceed? (what precautions)
AIRBORNE , negative pressure room, N95
I forgot to raise the side rails and now Jack Jill is on the floor! What is this?
NEGLIGENCE (you're gonna get in trouble....)
Your peep in room 38 just got back from having surgery. What are you gonna do for this patient to ensure they do not have any post op complications (give me 3 answers and why)
SCDs or TED hose to prevent DVT
Encourage IS or cough and deep breath to prevent PNA
Administer those pain meds.
"There's a fire Nurse Jackie, what do I do?" (the fire is in a small garbage can in the break room)
RACE
rescue, alarm, contain, extinguish/evacuate
ABC...123...who you gonna see FIRST?
Fractured leg, lots of pain, screaming at staff
kid with asthma who is still wheezing after two treatments (sats are 90)
post op hip replacement with weak pulse on foot
Airway ---- kid with asthma still having wheezing after two breathing treatments
I got the COPD but my sats are 90%. I fine watching tv in this hospital bed. Does this patient require oxygen (trick question....)
88-92% is standard for COPD. But read your doctors order. And never give a COPD more than 3L NC in this situation.
Justice, Fidelity, Confidentiality, Beneficence....what do you know about these?
justice - treat all patients equal and fairly
confidentiality - keep client information private
Fidelity - faithful, loyal, keep your word
Beneficense - prevent harm, obligation to act on the best interest of the patient.
a Living Will is best described as what.....
Instructions regarding future healthcare decisions (the client's wishes)
I am a baby and in a lot of pain. What scale might you use?
FLACC
"I am SOB, lay me flat so I can get comfortable" and Nurse Jackie says what?
Sir, I am going to put you in a Fowler's position to promote lung expansion
I got urinary retention.... what are some signs of this?
frequent small voids, bladder distention, incomplete bladder emptying
Pressure injury prevention includes
turn every two hours, keep skin clean and dry, use support surfaces, adequate nutrition and hydration
what does HGB do?
It carries oxygen to my cells....
Your patient has a catheter....tell me about catheter care
perineal care, no loops, keep bag below bladder, do not let that bag fill up...
what lab would I look at if I want to know the kidney function
the CHEMISTRY
"I am refusing all my meds today nurse". What do you do?
1. crush them and put in her drink
2. tell the family to give them to her
3. explain the risk and notify the provider
Number 3!!!!!