Better to be Safe than Sorry (Safety)
You enter your patient's room to find them resting in bed with the bedside table overtop of their lap, urinal on bedside table, call bell laying on bedside table, hemorrhoid cream on nightstand, SCDs on, water spilt on floor, armband taped to white board, and allergy band hooked to their bedrail. What are you going to fix in this room?
urinal on table, hemorrhoid cream, water on floor, armband on white board and allergy band on bedrail.
You are assessing your patients apical pulse. Where will you listen, for how long, and what 2 sounds will you hear?
5th intercostal space. midclavicular line
1 full minute
S1 lub and S2 dub
A client asked about glaucoma and what causes it. What should the nurse explain as the primary cause of glaucoma?
An increase in intraocular pressure.
Your patient is struggling with ADLs such as feeding themself and brushing their hair. Who can we consult to help with this?
Occupational Therapy
You are caring for a patient who just had an endoscopy. They are on antibiotics, taking oxycodone, and drinks about 1.5L of fluid daily. What factor puts them at highest risk for constipation and WHY?
What are the 3 questions we should ALWAYS ask our patients upon entering the room?
Name, DOB, and allergies
When assessing a patients pulses (radial, pedal, and carotid), which pulses will be felt simultaneously, and which will be felt separately?
Check radial and pedal at same time (checking for same rate, rhythm and strength)
Check carotid separately (if check together, patient can pass out)
How can we assess sensation in our patients BUE?
Have patient CLOSE EYES while touching both arms and ask where they feel it? If felt in both places, ask if it feels the same.
You are caring for a patient who has left sided hemiplegia that ambulates with a cane. What side of the body should they hold the cane with and what side of the client should you walk on?
They hold the cane in their right hand and you walk on the left side.
You are preparing an enema for an adult patient. What position will they lay in and how far will you insert?
Left side lying (sims) and 3-4"
You have a confused patient who is continually getting oob and fell on the previous shift. We have tried using diversional activities, the bed alarm, and a posey bed alarm but none are working. Name 2 other interventions you could use to keep the patient safe?
Posey vest, 4 side rails, tele sitter, sitter, move closer to nurses station.
You are asked to obtain orthostatic vital signs on your patient who is 3 days post-op. How will you complete your vitals and what s/s would you see if orthostatic?
Take the vitals with the patient laying down, then standing, and standing again after 3min.
S/S- Dizziness, Blurry vision, nausea.
A decline of ≥20mm Hg in systolic or ≥10 mm Hg in diastolic. Increase in HR by 15-30BPM
Your patient has a history of peripheral diabetic neuropathy. What finding can we anticipate in their assessment?
n/t to bilateral fingers and toes
Your patient ambulated OOB to BR and then sat in the chair. Where are you going to document this in the chart?
Care Interventions: Activities/Position
You are taking care of a patient with a Foley catheter and over the past 8 hours you observe 150mL of output. What is the expected urine output for this patient?
30mL/hr which equals 240mL/hr
What are the six rights of medication adminstration?
Right Patient
Right Medication
Right Dose
Right Route
Right Time
Right Documentation
You enter your patients room and they report chest pain along with SOB. Upon checking their VS, their HR is 132 with a BP of 167/98. What data is subjective and what is objective?
Subjective- Chest pain and SOB.
Objective- HR 132. BP 167/98.
You are speaking to an older adult with presbycusis. What tone and pitch of voice should you speak in?
Speak in a normal (or deeper) tone and do NOT raise pitch.
Type of pressure ulcer with soft tissue and bone/ligament exposure?
Stage 4
The nurse is educating a patient on taking Lasix. When should we tell the patient to take this medication and what lab value would we want to monitor?
Take in the morning and monitor potassium as it is potassium-losing diuretic.
When getting VS, what are normal VS ranges for an adult pertaining to HR, RR, and BP (systolic and diastolic)?
HR 60-100
RR 15-20
SBP <120
DBP <80
Your patient has a HR of 150, RR of 30, temperature of 101.2, and BP of 86/42. What terms would you use to describe each VS.
HR- Tachycardic
RR- Tachypneic
Temp- Febrile
BP- Hypotensive
You have a patient with chronic hypertension. Which sense are they most likely to have problems with?
Sight (vision loss)
You are caring for a client with impaired mobility d/t a L femur fracture. Patient is WBAT on LLE and uses a walker to ambulate. You are working with this patient 2 days post op. What is an appropriate nursing goal for this patient?
Patient will ambulate 30ft from bedroom to bathroom with use of assistive device by end of shift.
You are caring for a patient who has a history of retention and had their Foley removed 8hr ago with no void. Which medication may you anticipate being ordered to help your patient void?
Tamsulosin (Flomax)