Assessing Away
RACE means
Rescue, alarm, confine and evacuate/extinguish
Goals for patients should be?
a. measurable, situational oriented, pt. involved, realistic, attainable
b. measurable, time oriented, pt. involved, realistic, attainable
c. measurable, oriented as needed, pt. involved, realistic, attainable
b. measurable, time oriented, pt. involved, realistic, attainable
perineal care
On initial assessment the b/p is extremely low. What is the first step for the nurse?
Recheck b/p and assess
What does I/O mean?
Intake / output
The diagnosis phase means the nurse is doing
making measurable goals and patient outcomes
Patient isn't tolerating the morning dose of a one a day order medication I have to individualize the plan but how
what is the night time teaching routine for a client with dentures?
removed at night to rest the gums and prevent bacterial build-up
Who is at the greatest risk for infection:
a. recovering total knee replacement surgery
b. patient with stroke like symptoms
c. patient who is dehydrated
d. well approximated abdominal incision
a. recovering total knee replacement surgery
what is Health literacy ?
Understand and use health-related knowledge
Mr Smith was on the floor again and is now back in bed as the nurse I will
assess for injuries
You want me to do this ROM exercise again for what reason
prevent joint contractures
I need to use this standard walker but I forgot my education please remind me
lift the walker and advance 6-8 inched when walking
removing personal protective equipment, first I remove
gloves
purpose of hand hygiene
remove disease producing organisms from the skin
3 primary reason for bathing
self image (appearance), circulation, and infection prevention
restraint is need when:
a. pt is walking around all night
b. pt is confused but when is in room will sleep is unable to get up
c. pt is pulling constant at the tube feeding tube
d. pt is obsessed with the bathroom but needs her sleep
c. pt is pulling constant at the tube feeding tube
please use the gait belt to reduce this common problem
musculoskeletal injury's to self and patient
I have not been up for days what should I do before getting out of my bed
dangle your feet over the side for a seconds before standing
action the nurse take to minimize the possible transfer of microbes from the dirty linens
Hold the dirty linens away from the body
shot time - I need to give the SQ using the right gauge and inch
25G 5/8 inch
I prevent a med error by doing this big step
reading the label 3 times
Yes the patient is + CDiff for my hand care I will use
soap and water every time
Which of the following is correct for documentation?
a. remembering to use good, and average for adequate details
b. document procedures prior to finalizing
c. at the end of the shift make all your notes to promote quality of care
d. document subjective/objective finding so they are concise, accurate, and relevant
d. document subjective/objective finding so they are concise, accurate, and relevant
Who will you see first?
a. patient with red area on buttocks
b. patient who is due for their ROM exercises
c. post surgical patient who has chest pain
d. post renal dialysis treatment patient who needs to go to the bathroom
c. post surgical patient who has chest pain