General
What Methods of Examination do you use in a Head to Toe Assessment
Inspection
Palpation
Percussion
Auscultation
What is included in a focused assessment for Respiratory system?
Inspection, palpation, percussion, and auscultation
Lung sounds and work of breathing
Chest shape and configuration
Oxygen saturation
Respirations should be even, unlabored, and regular at a rate
Cough, SOB, sputum
What is included in a focused assessment for GI
Abdominal size, sounds, firmness, distention, pain and tenderness, BMs, passing gas, appetite, any N or V,
How often does a CVAD dressing and caps need to be changed? what is included in your assessment
Every 7 days
Documentation of external length
Site, drainage, patency of line
What is included the a pain assessment?
Pain scale 0-10
Non verbal cues: groaning, moaning, fetal position, guarding
Pain medication and med response
Location, intermittent vs constant, radiating, localized, burning, cramping, stabbing
When completing your skin assessment, you discover a stage 2 pressure injury to the coccyx?
What are your next actions?
Consult Wound care, Dietician, OT
Off-load and turn & reposition
Dressing
Document: location, size (LxWxD), drainage, odour, present on admission, dressing
What are major risk factors for a patient’s alterations in respiration?
Asthma, COPD, pneumonia, allergies, cigarette smoking, trauma, fluid overload, transfusion of blood and blood products, medication, drowning, and smoke inhalation and chemical inhalation
The nurse is caring for a patient with an indwelling urinary drainage catheter. What is included in the urinary system assessment?
Urine colour, amount, sediment, odour
Palpation of the abdomen
Securement of tube
Indication for the inserted catheter and reassess need for ongoing use
What should you do before applying AED pads?
Before pressing the shock button, what safety checks should be done?
Proper placement of AED pads, shave if hairy, wipe down if sweaty, avoid pacemaker and jewelry
Check if all clear and remove oxygen sources
What are signs and symptoms of delirium?
What assessment scale must be completed daily?
Confusion
CAM
What do you apply if you see muscle, tendon, bone when completing a VAC dressing change?
The pump is off when you enter the room. The pt states that he turned it off 3 hours ago. What are your next steps
Adaptic
Mepitel One
Gauze
Complete a VAC dressing change
During an assessment at a change of shift, the nurse finds the patient restless, irritable, confused, and with a decreased level of consciousness. What is the nurse’s next steps?
Assess:
Oxygen saturation
Vital signs
Resp rate and depth
Hypoxia
When assessing a NG tube feeding, what is part of the assessment?
NG placement: internal length
Pt tolerance, HOB, gastric residuals
Cerner Orders: formula, water bolus
Pump settings: rate and volume to be absorbed
Bag change
How long can an IV be in-situ according to the new policy?
What is included in the assessment of an IV site?
7 days. Skin antisepsis with CHG 2% and Alc 70%
Site: redness, drainage
Patency, dressing, pain with flushing
You have an order for Hydromorphone 0.5mg every 1 hour.
Do you require an order for a sub-q set insertion?
How long can it stay in-situ?
Can it be used for multiple medications?
No, 7 days, No
Which are signs or symptoms of dehydration?
Skin remains in the pinched position for more than a second or two
Concentrated urine
Dry lips
Low Blood pressure
Chest tube bubbling, what is included in your troubleshooting actions?
Air leak: check connections, taped connections
Xray: Chest tube placement
Resp assessment, subq emphysema
Drainage container: water line
A patient is tolerating tube feedings well without any signs of intolerance. The nurse checks the patient’s GRV and obtains 150 ml.
Which action should the nurse take next?
Return feed to patient.
Name 3 situations when a CODE ERT should be called?
Reduced LOC
Bradycardia or Tachycardia
Hypotension and Hypertension
Distressed breathing, Low O2 sat
When assessing a patient’s LOC, the nurse observes that the previously alert patient cannot provide a name or current location. What should the nurse do next?
GCS
Vital signs, lab work
Stroke assessment
Notify attending physician: delirium workup
Heparin Drip Module for VTE has been ordered on your patient?
Cerner order: weight 65kg
Loading dose: 3500 IV push once
Bolus: 2500 IV push every 6hrs PRN
Rate: 16mL/hr
What are your next steps?
Gather supplies: Heparin bag and tubing, IV pump
IV insitu and patent
Baseline bldwk drawn
PTT ordered 6 hrs post initiation
You have been tasked to complete trach care on your pt.
What does this include?
1. Equipment care (hood, trach ties, corrugated tubing, suction, O2)
2. Stoma Care (Assess skin in/around stoma, cleanse/dry skin, apply appropriate dressing etc.)
3. Airway management (assess for airway patency and change inner cannula)
Your Patient states that they have not had a BM in 3 days. What are your next actions?
Bowel protocol
Notify attending physician
Assess Pt medication, diet and fluid intake
After a Code Blue is called what are the primary steps to be done?
Start CPR
PPE
Crash cart to bedside
Backboard under patient
WOW at bedside
Primary Nurse to give SBAR to code Team
You receive an order to start a CADD. The Pharmacist Tech brings it down to the unit.
What supplies are required?
What are the steps required for initiation?
Sub-q set, cap, dressing, flush, alcohol swab
CADD: Tubing
Scanning Pt. arm band, scanning medication, witness, IDC for pump settings, Pt. education