Decompensation
GI
Interventions
Infusions
Policies & Procedures
100

Youy feel your patient is not doing well. You call your ANM for help. You request to call RRT. She says no.

What is your next action?

Call RRT...anyone can call. even patients 

100

Your patient is on Nepro tube feeding and having abdominal distention, nausea, vomiting, and abdominal pain. Which interventions are most appropriate at this time?

Sign of feeding intolerance 

Stop the feed for one hour and reassess 

100

What are nursing interventions for lung expansion in a patient with a chest tube?


Cough, deep breathe, ambulation, incentive spirometer.

100

What is the desired outcome for the aPTT when a patient is on a hearing drip?

therapeutic level 

100

Per AdventHealt lift policy, you should not live more than ____ pounds. If you have to lift more than ___ pounds, you must use lift equipment. 

5 pounds 

200

These interventions will achieve what outcome: Blood cultures, lactic acid, antibiotics, start saline, take vitals

BLAST or 0-3 hour bundle

Treat sepsis 

200

Your patient is NPO after midnight for an EGD. Medical history: DM

What is a possible complication for this patient, and how can we prevent it?

Hypoglycemia 

Contact provider to obtain orders for dextrose gtt when anticipating NPO status >4hrs on diabetic patient.

Do NOT hang D10 without an order. 

200

During BSH, the day nurses complained about how much food the patient eats. She states, "She eats Belvita biscuit cookies all day, like I mean ALL day!" The glucose at 1800 was 323 and was covered with Prandial and SSI. 

At 1900, What is your immediate concern?

Hypoglycemia,

Eating carbs within 2 hours of an accucheck and >180-the provider needs to be notified. 

200

 Titrate this gtt in units/kg/hr, NOT ml/hr

What is a Heparin gtt?

200

True or False:

Is it a very good idea to review the last 24 hours' progress notes at the start of your shift to gain an understanding of your patient.

True

300

During your assessment, you notice a change in your patient. 

Vital signs: 101F, 120, 120/80, 26, 99% RA

The patient reports increased SOB and a productive cough. 

What is your concern?

Sepsis

300

You are caring for a patient with an NGT. The charge nurse askes you to verify placement at the start of your shift.

 What interventions can achieve this outcome?

1. auscultate in the LUQ 

2. Look at the measurement the previous nurse documented and the measurement at insertion 

3. Aspirate GI contents 

300

A patient post-op day 4 from a hip replacement is now showing signs of an SBO. The patient is now NPO pending CT results. You notice the accuchecks are ac&hs. What needs to be done now?

Change accuchecks to q 4 hours and notify the provider. 

300

You are verifying PRBC with a nurse. You notice the rate is set at 25mL/hr. 

What other information do you need to obtain?

The planned rate?

PRBC will need to be infused in less than 4 hours. 

300

True or false:

If you do not complete mandatory education by the due date, will you receive a corrective action?

True, corrective actions will decrease your ability to transfer for up to one year. 

400

15 minutes into your blood transfusion, you notice the patient is moving around a lot and appears uncomfortable and anxious. They complain of back pain. What is your immediate concern?

Possible blood transfusion reaction 

Stop the transfusion, assess, take vitals, and notify the provider. 

400

Your patient has a PEG tube receiving TF at a rate of 45mL/hr. During BSH, the nurse reports GI WNL and proceeds to check gastric residual with you. 

Should this be avoided in this situation?

Yes, gastric residual only when there are signs of feeding intolerance. 

400

Your patient is NPO starting at 0600. The PCT reports a glucose of 189 at 0730. While reviewing the MAR, you see Prandial Insulin and SSI. 

What should be avoided in this situation?

Hold Prandial and give SSI 

400

You started a blood transfusion at 0915. What time will you complete vital signs?

0915, 0930, 1015, 1115, 1215, 1315

400

True or false:

As a nurse in FL, you must join CE Broker before you renew your nursing license. 

True. 

CE Broker | Continuing Education Management 

They will keep track of your CE and report it to the state. 

500

You are caring for a patient on a heparin drip for bilateral PEs. The patient has no medical history. She is a stay-at-home mom with three kids. She started complaining of a "stress" headache, which she reports she gets all the time. You give her Tylenol. 1.5 hours later, the headache is the same. 

What is your immediate concern?

Brain bleed...stat assessment and call the provider 

500

What port should medications be administered through a GJ Tube?

G
500

Patient is NPO. Accu check every 4 hours. 

Glucose 221.  

SSI: >70: call the provider and initiate hypoglycemia order, 71-150: 0 units, 151-250: 3 units, 251-351: 6 units, >351: call provider 

What needs to be done now?

Administer 3 units 

500

You obtained 1 unit of PBRC at 0945. On your way to start the blood, one of your patients fell and is fine. It is now 1010. What needs to be done now?

Administer the blood; we have to return blood after 30 minutes of arrival 

500

List one reason why BSH is so helpful!

  1. If your patient dead?

  2. Are you set up for failure? Pain, IV site, IVF, drains, potty 

  3. NEURO assessment!!!! NEURO assessment!!!! 

  4. Avoid mistakes by involving the patient

  5. Great was to learn!! 

  6. Improves communication 

  7. Saves time by reducing need for clarification and streamlines transition of care

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