Patient Experience
Infection Prevention
Falls
Patient Safety
Neuro Precautions
100
What to do if the patient is asleep during BSR?
Do not wake the patient up unless the patient has requested to be awake during BSR. This information can be obtained during purposeful rounds or as part of the development of the patient’s “What matters most to me” items
100
True or False:
The silver side of the silverlon dressing should be facing up.
False. The silver side must be activated by normal saline and should be facing down to protect the patient.
100
The Morse Fall Score should be documented within ___ minutes of a patients arrival
30
100
A non-violent restraint order is good for ___ hours
24
100
True or False:
A patient who is on nasal precautions should be encouraged to use an incentive spirometer.
false
200
Name the Four P's in Purposeful Rounding
Pain, Position, Personal hygiene/Potty, and Possessions.
200
Continuous tubing is good for ___ hours and intermittent tubing is good for ___ hours
Continuous tubing is good for _96_ hours and intermittent tubing is good for _24_ hours
200
What determines if the patient is a fall injury risk vs fall risk? List at least one factor.
Fall with injury risk (yellow band with red stripes)
One or more factors: >85 years old, bone condition, bleeding disorder, post-op patient with risk of wound dehiscence.
200
True or False:
A patient with a Braden Score of 15 should be on a P500 mattress
True! PUP measures should be initiated = or <18 and a P500 bed should be ordered for patients who are at risk for skin breakdown.
200
How often should a hemovac drain be emptied/documented?
Every 8 hours.
300
When giving a medication, what are the three KEY points that should be reviewed with the patient?
name (generic/brand), reason, & side effects.
EX) docusate/colace, stool softener to help prevent constipation, stomach/abdominal pain, nausea, diarrhea, weakness.
300
A patient has a foley and you are completing your safety checks. Name three things you should be looking for that are part of the CAUTI bundle.
-Catheter secured, Red seal intact, bag below bladder, unobstructed urine flow, bag emptied <3/4th full, free of visible soil, daily antimicrobial baths
300
True or False:
An incident report should be mentioned in the patient's chart after completion
False - An IR should never be mentioned in a patient's chart & is strictly for the organization to review.
IR - Factual summary of what happened. Data. Assessment. Results. (DAR method)
300
The CDC recommends washing our hands for a total amount of ____ seconds.
20
300
What is an incentive spirometer used for and how often should patients use it?
Promotes effective coughing and deep breathing which prevents atelectasis, bronchial secretion accumulation, and stasis pneumonia.
Recommend using 10 times every hour or in between commercial breaks. Needs to be documented in Epic twice daily. Document 0 if patient refuses.
400
Name 3 interventions to help patients maintain a quiet environment.
-Make sure all patient’s doors are closed.
-Purposeful rounds
-Turn off light & TV or offer a quiet kit which includes headphones.
400
The disinfectant times are ___ for the prime cloths and ___ for the bleach cloths
1 and 4
400
List interventions for a high fall risk patient
-bed low & locked & mats in place
-bed/chair alarm on and plugged into wall
-remain within arms reach
-Fall prevention bundle - yellow socks & yellow blanket
-High fall risk stop sign
400
True or False:
PT and OT are required to assess and mobilize patients prior to the nurse or tech.
FALSE - it is important to get patients up and out of bed as soon as possible. Utilize lift team if the patient appears to be weak. Mobilization prevents DVTs, pneumonia, etc.
400
A patient has arrived to the unit and has an order for seizure precautions. What interventions should be in place?
-Ambu-bag
-Nasal Cannula
-Padded side-rails (blanket)
-Suction set-up
-Continuous pulse ox
500
Name 3 key points to help improve discharge communication.
-Include family (if available) & patient in the conversation when reviewing information
- Highlight & review specific medication times
-Answer any questions & quiz the patient on medications. Make it fun!
-Utilize Healthwise and include educational handouts
500
Identify the five moments of hand hygiene
1. Before touching a patient
2. Before a procedure
3. After a procedure of body fluid exposure risk
4. After touch a patient
5. After touching a patients surroundings
500
Post fall management - what is the nurses responsibility?
-ensure patient is safe (utilize lift team if needed)
-assess (vitals, head to toe)
-notify provider, charge nurse, and manager
-complete post fall huddle on huron
-complete IR and notify family
-reassess for video needs and complete new morse fall score
500
A urine sample is collected. What should be written on the specimen label?
Badge number, date/time, and initials
500
Name at least one trigger which can cause autonomic dysreflexia in spinal cord injury patients
AD - A medical emergency in spinal cord injury patients at level T6 and above. A sympathetic overactivity leading to vasoconstriction below the neurological lesion. Responsible for headache, flushing, sweating, and nasal congestion. Triggers include bladder distention, bowel distension, pressure ulcers, fractures, DVT's, & PE.