Wound Care
This type of tissue is beefy red, moist, and indicates a wound is healing properly.
What is granulation tissue?
This "Right" of medication administration is being verified when you ask a patient to state their name and date of birth.
What is Right Patient?
This is the most effective way to break the "Mode of Transmission" in the Chain of Infection.
What is hand hygiene?
This is the maximum amount of time (in seconds) that a nurse should apply suction during a single pass.
What is 10 to 15 seconds?
This structural change in the older adult’s chest leads to decreased lung expansion and "barrel chest" appearance.
What is calcification of costal cartilage or increased AP diameter?
A patient’s abdominal wound has opened, and the bowel is protruding. This is the first action the nurse takes.
What is covering the area with sterile gauze soaked in sterile saline?
This is the priority nursing action if a patient refuses a life-saving medication.
What is assessing the patient’s reason for refusal and providing education?
You are entering the room of a patient with Tuberculosis. This is the specific PPE you must wear.
What is an N95 respirator mask?
These two pieces of emergency equipment must always be kept at the bedside of any patient with a tracheostomy.
What are an extra trach of the same size/one size smaller and an obturator?
This is the target SpO2 range for a patient with chronic COPD to prevent suppressing their hypoxic drive.
What is 88% to 92%?
This lab value, if lower than 3.5 g/dL, is the strongest predictor of delayed wound healing in a chronic pressure injury.
What is Serum Albumin?
For a medication with a "narrow therapeutic index," the nurse must monitor these two lab levels to ensure safety.
What are Peak and Trough levels?
A patient with C. Diff requires this specific hand-hygiene modification that alcohol-based foams cannot provide.
What is washing with soap and water?
During suctioning, the nurse should only apply suction during this phase of the procedure.
What is while withdrawing the catheter?
An older adult patient has a diminished cough reflex. This is the primary respiratory complication the nurse must monitor for.
What is Aspiration Pneumonia?
This specific dressing type is best for a stage 2 pressure injury with minimal drainage because it maintains a moist environment and protects from friction.
What is a Hydrocolloid dressing?
After discovering a medication error, this is the very first thing the nurse does before calling the provider or filing a report.
What is assessing the patient's vital signs and status?
This type of precaution is required for a patient with Meningitis or the Seasonal Flu.
What is Droplet Precautions?
If the patient’s heart rate drops or SpO2 falls significantly during suctioning, the nurse must do this immediately.
What is stop suctioning and hyper-oxygenate with 100% O2?
This respiratory delivery device provides the most precise concentration of oxygen and is the "gold standard" for COPD patients.
What is a Venturi Mask?
You notice a wound has thick, yellow/tan stringy tissue that prevents the wound bed from closing. This is the name of that tissue and the required intervention.
What is slough and debridement?
Because of decreased hepatic blood flow and renal clearance in older adults, they are at an increased risk for this pharmacological phenomenon
What is cumulative drug toxicity?
During a sterile dressing change, the nurse realizes they reached over the sterile field. This is the only acceptable next step.
What is discarding the entire field and starting over?
This is the primary reason we provide humidified oxygen to a patient with a tracheostomy.
What is to prevent the drying of secretions and the formation of a mucus plug?
When collaborating with an Interprofessional team for a COPD patient who is too tired to eat, the nurse should ask this professional for high-calorie, small-volume meal planning.
Who is the Registered Dietitian?