Decompensation
You 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
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
What are nursing interventions for lung expansion in a patient with a chest tube?
Cough, deep breathe, ambulation, incentive spirometer.
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
Your patient vitals are BP 101/54, HR 125, RR 20, Temp 101F, O2 sat 100% on room air. What is your biggest concern?
Sepsis, need to start 0-3hr bundle if MD on board with plan
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.
A nurse is starting a heparin gtt. They obtain baseline labs, administer the gtt with a bolus injection. One hour later, the baseline PTT results as 35. What should the nurse do next?
Do not act on PTT, this is just a baseline. PTT due 6hrs after gtt initated and can adjust based on that PTT.
Based on your knowledge of effective bedside handover, how would you ensure a comprehensive transfer of information during the handover process to improve patient safety and care continuity? Include key elements you would address, plan how you would verify the information has been communicated clearly.
Your patient vitals are BP 101/54, HR 125, RR 20, Temp 101F, O2 sat 100% on room air. What order of interventions do you anticipate?
Contact charge, contact provider, initiate sepsis protocol, blood cultures, lactic, antibiotics, fluids, take vitals again after interventions (BLAST)
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
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.
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.
During bedside handover, you notice tubing expired at 0600 for a continuous infusion that is connected to a central line. What are your next steps?
Ask nightshift before they leave to change tubing and write “no” next to tubing properly labeled on peer-to-peer sheet and write that nurse changed before they left.
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.
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.
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
You started a blood transfusion at 0915. What time will you complete vital signs?
0915, 0930, 1015, 1115, 1215, 1315
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 to the provider
What port should medications be administered through a GJ Tube?
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
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
Patient is admitted to your unit with a central line. It is showing signs of infection, what do you do?
Involve charge, IP, and provider