Iron Man
15 minutes into your blood transfusion, you notice the patient is moving around a lot and appears uncomfortable and anxious. They complain of back pain. What is your immediate clinical concern?
Possible blood transfusion reaction
You anticipate your patient will be NPO for more than 4 hours, what are your next steps?
Contact provider to obtain orders for dextrose gtt when anticipating NPO status >4hrs on patient.
Do NOT hang D10 without an order.
You are caring for a patient on a heparin drip for bilateral PEs. The patient starts complaining of a "stress" headache, which they reports gets all the time. You give her Tylenol. 1.5 hours later, the headache is the same.
What is your immediate concern?
Brain bleed
Your central line tubing is expired, but the patient is not using any IV medications. What do you do?
You obtained 1 unit of PBRC at 0945. On your way to start the blood, one of your patients fell and is fine. It is now 1010. What needs to be done now?
Administer the blood; we have to return blood after 30 minutes of arrival
Your patient is NPO starting at 0600. The PCT reports a glucose of 189 at 0730. While reviewing the MAR, you see Prandial Insulin and Correctional Insulin.
What should be avoided in this situation?
Hold Prandial and give Correctional Insulin
Where do you verify a patient's isolation status in EPIC?
Follow the storyboard and what Epic tells you to do.
During bedside handover, you notice tubing expired at 0600 for a continuous infusion that is connected to a central line. How do you proceed?
Ask nightshift before they leave to change tubing and write “no” next to tubing properly labeled on peer-to-peer sheet and write that nurse changed before they left.
You started a blood transfusion at 0915. What times will you take vital signs?
0915, 0930, 1015, 1115, 1215, 1315 and at completion
Patient is NPO. Accuchecks every 4 hours.
Glucose 221.
Correctional Insulin: <70: call the provider and initiate hypoglycemia order, 71-150: 0 units, 151-250: 3 units, 251-351: 6 units, >351: call provider
What needs to be done now?
Administer 3 units
You feel your patient is not doing well. You call your ANM for help. You request to call RRT. She says no that's their baseline.
What is your next action?
Call RRT...anyone can call. Even patients
A nurse is starting a heparin gtt. They obtain baseline labs, administer the gtt with a bolus injection. One hour later, the baseline PTT results as 35. What should the nurse do next?
Do not act on PTT, this is just a baseline. PTT due 6hrs after gtt initated and can adjust based on that PTT.
What rate should you set the pump during a blood transfusion?
Set rate to be completed with 2-4hrs
Your patient vitals are BP 101/54, HR 125, RR 20, Temp 101F, O2 sat 100% on room air. What interventions do you anticipate?
Initiate sepsis protocol: blood cultures, lactic, antibiotics, fluids, take vitals again after interventions (BLAST)
Name 2 nursing interventions for lung expansion in a patient with a chest tube?
Cough, deep breathe, ambulation, incentive spirometer.
Patient is admitted to your unit with a central line. You do not note any signs of infection. What are your next steps regarding the line?
Notify charge nurse