NAME THAT BREATH SOUND
short and high in pitch, these can be heard when fluid is in the lungs
Fine crackles
What is the first sign of respiratory distress in infants?
increased respiratory rate (Tachypnea)
Mrs.M has received 760mls of IV fluid & has had 140mls of tea. she has voided 540mls of urine & vomited 110mls. What is Mrs.M's fluid balance?
+250mls
What does the acronym SBAR stand for?
Situation, Background, Action, Response/Recommendation
Mrs. M has heart failure. She is ambulatory in the hall when she suddenly collapses. What is the priority nursing assessment by the nurse?
Observe for or establish a patent airway (ABC)
longer, low pitched, can be caused by aspiration, pulmonary edema, pneumonia
course crackles
The nurse needs to take vital signs on a 6 y.o patient. The cuff available is too small. What should the nurse do?
Use the next largest cuff, even if too big
A resident on your unit has been diagnosed with scabies. The nurse knows he should use the following precautions:
Contact
Mr. Man appears lethargic and flushed. The nurses assesses and decides to do a set of vital signs. Where are these vital signs documented?
NEWS2 Tool
Mr. J has an IV with NS running at 75ml/hr. The nurse notices the IV site is red, swollen and warm to touch above insertion point. What should the nurses 1st action be?
stop the IV infusion
similar to the sound of air
normal
List 3 ways to assess hydration status in an infant.
mucous membranes, tears, eyes, fontanels, urine output, cap refill, BP, pulse, skin turgor, thirst
The physician orders Flagyl 3.6 grams per GT to be given QID in divided doses. The pharmacy prepares the dose accordingly. How much medication will be delivered in each dose?
900mg
An Interdisciplinary Focus List should be initiated within what time frame after admission to HTS?
72 hours
your 12 y.o patient is receiving his 1200 enteral feeding. He is awake and alert but you notice his RR is 34. What is your first nursing action?
stop the enteral feeding
high pitch, inspiratory sound that is produced by airways with severe narrowing
stridor
the nurse is taking VS on a 1 y.o patient. The O2 sat monitor is alarming and reading Sp02 84%. What should the nurse's initial response be?
Look at the patient; general survey. Assess general appearance.
Mrs. J is admitted to hospital with heart failure. The nurse enters his room and finds him unresponsive and cyanotic. What is the priority nursing action?
Call for help.
Mr. M falls while being transferred to bed. Incidents/patient safety events must be documented in which 2 places?
health record, RL6
Mr. M has a seizure disorder. He is on VPA & Lamotrigine. Seizure activity has increased from 1-2 sz/month to 6-7 sz/month. The nurse notices in the recent bloodwork that the VPA levels are sub-therapeutic. What should the nurse do?
Call the doctor to reassess VPA dosage.
musical sound produced primarily during expiration by airways
wheeze
Name 3 signs of increased respiratory effort in babies and children
nasal flaring, chest retractions, head bobbing, use of accessory muscles, open mouth breathing, gasping, grunting
Mrs. M has struggled with frequent constipation. She has a bowel regime starting on Day 2 without a BM. List 3non-medicinal interventions to help Mrs. M have a BM before the use of prn medication.
increase water, increase fiber, increase activity, fruit lax, prune juice
What is 'chart by exception' documentation method?
when you document unusual, out of norm/baseline or abnormal findings
**normal or routine findings documented on flow sheets
Mr. F is c/o pain. His nurse administers 50mg of tramadol which is ordered PO q4h prn. 2 hours later, Mr. F tells his nurse he is experiencing severe pain. What should the nurse do?
request the Dr. evaluate Mr. F and his need for increased pain meds