Pre-Shift
What is the objective of giving a report and what should be included in report?
The objective of providing a report is to paint a clear picture to the oncoming nurse how to take care of the patient safely.
The report includes the primary diagnosis, medical history, doctor’s orders (e.g., vital sign frequency, spinal assessments), abnormal findings from the head-to-toe assessment, and relevant lab and radiological results, cognition (e.g. GCS), mobility status and etc.
A good report illustrates the patient and how to take care of them safely. While a poor report does not.
You just finished report, what is the first thing you would do before entering a patient's room
Hand-washing
When completing vital signs, the nurse notes that the blood pressure is 190/100 on the left arm. The patient is asymptomatic for headache, chest pain or dizziness. What should the nurse do?
Repeat blood pressure on opposite arm. If still high, do a manual blood pressure.
On initial assessment, the nurse notes that the patient is not very conscious and thus completes a GCS test and scores 5/15. The nurse also completes a set of vital signs and it shows :
BP - 120/80
HR - 80
SpO2 - 65%
RR - 18
What should the nurse do?
Call for help
Head of Bed Up
Give Oxygen (up to 15L)
Look for PRN Puffers
Get Yankeur suction
Call RT / Rapid Response / Code Blue and notify Physician if not already
You have completed all checks and verbalized all rights. You are now at the patient bedside.
Describe the steps to give an SC and IM to a patient. Include needle gauge and steps
SC - Swab, insert 45-90 degrees while pinching
- Length of Needle : 0.5" - 1"
IM - Swab, insert 90 degrees while Z-tracking
- if injecting 0.5-2 mL, Length of Needle: 1”-1.5” at deltoid
- if injecting 2-3mL, Length of Needle: 1.5" at ventrogluteal
After receiving the report from the departing nurse, you, the incoming nurse, will check the charts. What is the purpose of chart checking?
The purpose of chart checking is to ensure that all relevant patient information is accurate, up to date, and complete.
For example, no orders are missed and all abnormal lab work are reported appropriately.
As you enter the patients room. You notice that the room has a sign that says "Contact and Droplet". What is the order of donning PPE?
Hand Hygiene
Gown
Mask
Eye Protection
Gloves
What is the order of Head to Toe when it comes to systems assessment?
Inspect, Palpate, Auscultate except GI
On initial assessment, the patient is complaining of 2/10 chest pain. What should the nurse do?
Call for help
Give oxygen
Give morphine, nitroglycerin
Prep for ECG
Notify physician if not done already
The nurse has completed all checks and verbalized all rights for the IV secondary minibag. How does the nurse know the safe rate for this minibag and its compatibility?
Parenteral Manual
As students, patient research will be completed. What is the purpose of patient research and what is included?
The purpose of patient research in student nursing is to gather comprehensive information so that they can take care of them safely.
This includes : medical history, current health status, and individual needs, facilitating personalized and effective care. This includes reviewing the patient's medical history, current medications, vital signs, diagnostic test results, chief complaints, psychosocial factors, cultural considerations, and care goals, ensuring a holistic understanding that enhances patient safety and treatment outcomes.
What are the four moments of hand hygiene?
Before contact with patient
Before clean/aseptic procedure
After body fluid risk exposure
After contact with patient and enviornment
Which of the following procedures are sterile/aseptic procedures? Wound care, NG Insertion, Foley insertion, Yankeur Suctioning
Wound care and Foley Insertion
On assessment, the patients blood sugar is 3.0mmol/L. Sweaty, cool and GCS changed to now 14. Is the nurse concerned? Why? What should the nurse do?
Hypoglycemia
Normal Blood Sugar is 4-8
Give juice, chewable glucose tablets, or IV Dextrose.
When are medication checks completed?
Pre-Check with Chart to Orders
1st Check
2nd Check
3rd Check
Bedside Check
At the beginning of shift, the nurse is checking the bloodwork of the patient to ensure safety. What is the difference between a low value and a critical value?
Example - which of these is low and which of these are a critical? (Normal Hgb >120)
HgB - 98
HgB - 62
A low value in bloodwork indicates a result that is below the normal reference range and may require monitoring or intervention but is not immediately life-threatening. In contrast, a critical value is a significantly abnormal result that poses a serious risk to the patient's health and requires urgent action. While both warrant attention, critical values necessitate immediate communication with a healthcare provider for prompt intervention.
In accordance with AHS policy criticals include :
- a hemoglobin level less than 70
- a sodium level less than 130 or greater than 150
- a potassium level less than 3.0 or greater than 5.0
You enter the patients room. How do you introduce yourself to patients in accordance to AHS policy?
Name
Occupaton
Duty
What are the 7 principles of sterility?
1. A sterile object remains sterile only when touched by another sterile object.
2. Only sterile objects may be placed on a sterile field.
3. A sterile object or field out of the range of vision or an object held below a person's waist is contaminated.
4. A sterile object or field becomes contaminated by prolonged exposure to air.
5. When a sterile surface meets/contacts a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action.
6. Fluid flows in the direction of gravity.
7. The edges of a sterile field or container are considered contaminated.
The student nurse is doing their initial assessment and notes that the patients GCS is 13 and not 14 as in accordance to the report given in the AM shift. However, the student nurse is not confident. What should the student nurse do?
NEVER BE AFRAID TO ASK FOR A SECOND OPINION.
This could indicate an acute change, but it might also be the patient's normal condition. However, it never hurts to get a second opinion, and it's better to ask and be SAFE THAN SORRY. Especially in the case of patient safety.
What are the 10 medication rights?
Right medication
Right dose
Right route
Right time and frequency
Right patient
Right reason/assessment
Right education
Right to refuse
Right evaluation
Right documentation