Stroke
This is the most common type of stroke, caused by an interruption of blood flow to the brain.
What is an ischemic stroke.
A lactate level at or above this threshold indicates tissue hypoperfusion and requires urgent intervention.
What is 2 mmol/L.
This standardized tool helps nurses identify patients at risk for pressure injuries by scoring sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
What is the Braden Scale.
To reduce both CAUTI and CLABSI, nurses must perform this daily action and document whether the device is still required.
What is assessing and documenting daily device necessity.
This simple intervention—performed at least twice daily—helps reduce oral bacterial load and is a core strategy in preventing hospital‑acquired pneumonia.
What is oral care.
In the BEFAST acronym, this letter reminds staff to check for sudden trouble with walking, dizziness, or loss of balance.
What is B — Balance.
Within the first hour of identifying sepsis, nurses must obtain blood cultures, start broad‑spectrum antibiotics, and administer this type of fluid.
What are IV crystalloids (such as normal saline or LR).
To reduce pressure on bony prominences, immobile patients should be repositioned at least this often.
What is every 2 hours.
To prevent CAUTI, the urinary drainage bag must always be kept in this position relative to the bladder.
What is below the level of the bladder.
Early and frequent use of this nursing intervention improves lung expansion, mobilizes secretions, and reduces the risk of HAP.
What is ambulation.
At Memorial Medical Center, this team must be notified immediately when a patient screens positive on BEFAST or has a last‑known‑well within 24 hours.
Who is the Code Stroke team.
A drop in systolic blood pressure below 90 mmHg, or a MAP below 65 mmHg, may indicate this life‑threatening progression of sepsis.
What is septic shock.
This type of product—applied to heels, sacrum, or elbows—helps reduce friction and shear forces that contribute to pressure injury development.
What are protective barrier creams or films.
Before drawing a blood culture from a central line, MMC policy requires nurses to replace this component.
What is the needleless connector.
To reduce VAP risk, the head of the bed for ventilated patients should be elevated to this angle or higher unless contraindicated.
What is 30 degrees.
This medication is MMC’s first‑line thrombolytic for eligible acute ischemic stroke patients.
What is tenecteplase (TNK).
After initiating fluids and antibiotics, nurses must repeat this lab test within 2–4 hours if the initial value was elevated.
What is a repeat lactate.
Patients at high risk for pressure injuries may require this type of mattress or overlay to redistribute pressure more effectively.
What is a pressure‑redistributing (or low‑air‑loss) support surface.
According to the VAD policy, transparent semipermeable membrane dressings on central lines must be changed at least this often unless soiled or loose.
What is every 7 days.
Before providing oral intake to high‑risk patients, nurses should perform this assessment to reduce aspiration‑related pneumonia.
What is a swallow evaluation.
After TNK administration, nurses must perform this assessment every 15 minutes for the first hour.
What is a neurological assessment (NIHSS‑based neuro check).
This lab test should be drawn before starting antibiotics, as it helps identify the source of infection and guide targeted therapy.
What are blood cultures.
Adequate intake of this macronutrient is essential for maintaining skin integrity and supporting wound healing in at‑risk patients.
What is protein.
Before accessing a central line, nurses must do this to disinfect the needleless connector.
What is scrub the hub.
Encouraging patients to use this device—often every hour while awake—helps improve lung inflation and prevent atelectasis‑related pneumonia.
What is an incentive spirometer.