General
What are the 5 P's? Give examples of how you implement the 5 P's
Pain, Potty, Position, Peripheral, Parting
When should pt receive their My Chart tablet? what is the password to get in? When should the tablet be returned to HUC?
-upon admission
-birth year
-upon discharge
What is the escalation process for telemetry to get in touch with someone if the leads are off, abnormal rhythm or inability to analyze rhythm?
Nurse -> Charge/ANM -> Rapid Response
Fluid intake for clients suffering from dumping syndrome should be:
A. Between meals
B. Only with meals
C. Anytime they want
D. Restricted to 1200 ml/day
Answer - A - Clients experiencing dumping syndrome should be advised to ingest liquids between meals rather than with meals
What patient should NOT be admitted on our unit?
A. Stroke R/O, q4 neuro checks
B. A patient with a troponin of 44, HX- CHF, ESRD, MWF dialysis, GERD
C. R/O MI, CP last reported 13 hours ago
D. Sepsis shock: HR- 99 BP-92/61 O2-96%
A. Stroke R/O, q4 neuro checks
Pt's on dialysis typically have their labs out of whack. We can accept R/O MI as long as pt has not reported CP in the past 12 hours. We can accept sepsis shock as long as HR is within normal range, SBP is > 90.
What patient's should get a CHG bath? How often? And what is each shift responsible for doing when it comes to CHG baths? What about surgical patients?
-Every pt should get a CHG bath
-Q 24 hours, Q12 hours for pt's with CL's and foleys
-Days- Odd rooms Nights- Even rooms
-Surgical pt's should get CHG baths at 5am on night shift
Name 3 instances that telemetry should be called and updated?
Pt in shower, changed rooms, moved to a different unit, discharged, refused telemetry, order discontinued, new tele order
After EGD, Edna was diagnosed to have gastroesophageal reflux disease (GERD). The nurse teaches Edna about ways to minimize symptoms. Which of the following statements made by Edna indicates that more teaching is needed?
A. “I will be sure to drink tea instead of coffee.”
B. “I will take a walk after I eat.”
C. “I will try to eat smaller meals more frequently.”
D. “I will sleep with the head of the bed elevated about 12 inches.”
Answer - A - The client with GERD is encouraged to eat smaller, low-fat frequent meals and to avoid lying down after eating. Clients are instructed not to eat for at least 2 hours before bedtime and avoid foods that decrease lower esophageal pressure, such as anything containing caffeine (coffee, tea, cola, and chocolate).
When giving a blood transfusion, when do you take the vital signs? Which Vital signs are REQUIRED?
before transfusion, start of transfusion, 15 minutes after transfusion started and every hour after. Vital signs that are required to be documented is BP, Temp, HR and respirations. O2 can be documented but is not required
Which of the following are not appropriate for the use of indwelling urinary catheters?
A. Assist in healing of open sacral or perineal wounds in incontinent patients.
B. Acute urinary retention or obstruction.
C. To measure I's & O's
D. Requires prolonged immobilization
C. To measure I's & O's
Name the 2 LETHAL rhythms
-Ventricular tachycardia
-Ventricular Fibrillation
-Asystole
-Pulseless electrical activity (PEA)
The nurse has just received instructions for an oral glucose tolerance test (OGTT) with a client. Which of the following statements made by the client indicates a need for more teaching?
A. “I will eat a light breakfast the morning of the test.”
B. “I will expect to take 100 mg of glucose at the start of the test.”
C. “I can expect to have my blood drawn at 30 and 60 minute intervals during the test.”
D. “I will report any symptoms of dizziness, sweating, and/or weakness if they occur during the test.”
Answer - A - “I will eat a light breakfast the morning of the test ” would indicate a need for more teaching. An oral glucose tolerance test (OGTT) is a fasting test and the client will be NPO after midnight prior to the test. All other responses identify appropriate client responses regarding to the test.
In what instance does a Baker Act patient NOT require a sitter?
When intubated in the ICU
Which WOWs/phones belong where? (Tell me which number WOW goes in which hallway) Which WOWs are dedicated to PCT's?
Hallway A: Wows 1-4 (#4- PCT)
Hallway B- Wows 5-8 (#8 PCT)
Hallway C- Wows 9, 10, 11 (no wow. use desktop)
Hallway D- WOWs 12, 14, 15 (no wow for PCT, use desktop)
How many seconds should the QRS complex wave be in a normal sinus rhythm?
0.04 to 0.10 seconds
A client underwent Billroth surgery for gastric ulcer. Post-operatively, the drainage from his NGT is thick and the volume of secretions has dramatically reduced in the last 2 hours and the client feels like vomiting. The most appropriate nursing action is to:
A. Reposition the NGT by advancing it gently NSS
B. Notify the MD of your findings
C. Irrigate the NGT with 50 cc of sterile
D. Discontinue the low-intermittent suction
Answer - B - Notify the MD of your findings. The client’s feeling of vomiting and the reduction in the volume of NGT drainage that is thick are signs of possible abdominal distention caused by obstruction of the NGT. This should be reported immediately to the MD to prevent tension and rupture on the site of anastomosis caused by gastric distention.
What is a code grey? Who is to report?
The decision to implement a “Code Grey” alert is made by any individual who feels there is immediate threat of harm or injury to themselves, the patient, or others. The “Code Grey” response team is the Security Officers on duty as needed.
A pt receives a minor skin tear when they bumped into the wall. What would be the MINOR skin tear treatment?
Minor Skin Tears:
1. Clean with normal saline.
2. Apply wound gel to wound bed.
3. Apply petroleum-based gauze to the wound.
4. Cover with foam dressing or dry gauze and wrap.
5. Change dressing every 3 days and PRN.
SHOW picture of Tele strip. Pt is symptomatic and has hypertensive heart disease. What do you do?
A. Assess patient
B. Call code, initiate CPR, defibrillate ASAP
C. Prepare for immediate cardioversion
D. Use transcutaneous pacing, consider atropine, do NOT give an antiarrhythmic
D. Use transcutaneous pacing, consider atropine, do NOT give an antiarrhythmic
The client presents with severe rectal bleeding, 16 diarrheal stools a day, severe abdominal pain, tenesmus, and dehydration. Because of these symptoms, the nurse should be alert for other problems associated with what disease?
A. Crohn’s disease
B. Ulcerative colitis
C. Diverticulitis
D. Peritonitis
Answer - B - Ulcerative colitis. Ulcerative colitis is a chronic inflammatory condition producing edema and ulceration affecting the entire colon. Ulcerations lead to sloughing that causes stools as many as 10-20 times a day that is filled with blood, pus, and mucus. The other symptoms mentioned accompany the problem.