Vitals Gone Wild
This is the first intervention for a patient whose SpO₂ drops to 88% on room air.
What is apply supplemental oxygen?
This is the appropriate action when a peripheral IV site is red, warm, and painful.
What is remove the IV?
These tasks can be delegated to a CNA for a stable patient, such as routine BP and temperature checks.
What are vital signs?
This antidote is commonly used for opioid overdose.
What is naloxone?
This is the first action when you find an unresponsive patient with no pulse.
What is start CPR?
This condition should be suspected in a patient with HR 120, BP 88/54, and cool clammy skin.
What is hypovolemia (or hemorrhagic shock)?
This is the first thing to check when a Foley catheter has no output for 2 hours.
What is check for kinks or obstruction in the tubing?
This action cannot be delegated because it requires interpretation of patient data.
What is nursing assessment?
This category includes medications like heparin and insulin.
What are high-alert medications?
This cardiac rhythm, commonly seen in sudden cardiac arrest, is treated with immediate defibrillation.
What is ventricular fibrillation (or pulseless VT)?
This syndrome is suggested by fever, tachycardia, tachypnea, and elevated WBC in an infected patient.
What is sepsis?
This must be re-established immediately if a chest tube drainage system is knocked over.
What is the water seal?
This must be done by the RN after delegating a task to ensure it was completed correctly.
What is follow-up (or evaluation)?
This is the correct action when a medication looks unfamiliar or different than expected.
What is verify the medication before administration?
This priority action is required when a patient becomes suddenly confused and lethargic.
What is assess the patient (and consider rapid response)?
This physiologic mechanism explains why a COPD patient may become drowsy after excessive oxygen administration.
What is CO₂ retention (loss of hypoxic drive)?
This technique is required when changing a central line dressing.
What is sterile technique?
This is required after receiving a critical lab value before notifying the provider.
What is assess the patient?
This must be confirmed before administering two IV medications through the same line.
What is compatibility?
This pulse check interval is recommended during CPR cycles.
What is every 2 minutes?
This electrolyte imbalance is commonly suspected with peaked T waves on telemetry.
What is hyperkalemia?
This complication is suspected when a chest tube stops draining and breath sounds are diminished.
What is tension pneumothorax (or tube obstruction)?
This responsibility cannot be delegated when the patient is stable and ready to be discharged.
What is discharge teaching?
This is the first priority after discovering a patient received 10× the intended insulin dose.
What is assess the patient, check blood glucose, administer standing order medication if needed, and notify the provider?
This is the maximum recommended pause in chest compressions during CPR.
What is less than 10 seconds?