Blood Transfusion
When are vital signs to be taken within the blood transfusion process?
within 1 hour prior to beginning
at the start of transfusion
15 minutes after the start of transfusion
within 6 minutes from end of transfusion
What is the #1 way to prevent a CAUTI from occuring?
Having no indwelling catheter
Where is the PCA pump key kept when not in use
In the Pyxis
Your patient has an order for D5 1/2 NS. You spike the bag at 12pm on Monday- when do you have to change the bag?
96 hours from the time you spiked it!
**this is only true for IVF that is commercially prepared and not manipulated by the pharmacy. These bags still have a 24 hour hang time.
What is the acronym we use for stroke?
B.E. F.A.S.T.
What needs to be included on a type and screen label?
Date, Time and Collectors Initials
How many RNs must be present for an indwelling catheter insertion?
2 RNs
How frequently does the RN need to chart a PCA assessment on the patient
q4hours
If there is a patient with suspected Malignant Hyperthermia (MH) , where can you locate the MH tackle box?
D7
OR
L&D (B7)
If a patient with Sickle Cell Disease complains of a severe headache, what is your next intervention?
Call the hematologist immediately, activate RRT/Code Stroke if indicated
How long is blood consent valid for?
30 days or the duration of treatment
TRUE or FALSE
A physician's order is required to remove an indwelling urinary cather
FALSE
When does the RN clear the PCA pump history?
During hand off/shift report
National Patient Safety Goals: What are the 3 main elements of a time out?
Right Patient, Right Procedure, Right Site
A patient goes to sleep normal condition at 9pm, wakes up at 3am and shows signs of stroke. What time is considered onset of symptoms?
Cannot be determined
If your patient complains of itchiness and shortness of breath, what is your PRIORITY nursing intervention?
Stop the infusion
You removed an indwelling foley cather from your patient at 6am. At 12pm, your patient still has not voided. What intervention comes next on the tiral to void algorithm?
Perform a bladder scan to see if your patient is retaining urine
How many RNs need to be present to initiate or change the rate on a PCA pump?
2 RNs for an independent verification
What triggers Malignant Hyperthermia and what are some of the signs and symptoms?
Anesthesia
Masseter spasm, Generalized muscular rigidity, Tachycardia, Hypercapnia, Hypoxia, Combined metabolic-respiratory acidosis
What does B.E. F.A.S.T. stand for
Balance, Eyes
Face, Arms, Speech, Time
What 5 items do you need in place to start the process of a blood transfusion?
pe and Cross, Physician Order, Signed Patient Consent, Base Line Vital Signs, Patent IV access
What does the CAUTI bundle consist of?
Daily review of catheter indication, M-Care hygiene, red seal remains intact, utilization of StatLock, no dependent loops or kinks, green clip is utilized, urine collection bag is below the bladder, urine collection bag is emptied prior to transport.
When initiating a PCA medication, how frequently does the RN take the vital signs, pain assessment and RASS?
q15minutes for 1 hour
q30minutes for 1 hour
q1 hour for 4 hours
Name safe sleep interventions
Nothing in crib
Flat on their back
Do not elevate HOB
Sleep sacks or swaddles to the shoulders
What diagnostic test needs to be performed with possible stroke patients?
CT Scan