Decompensation
Youy feel your patient is not doing well. You call your ANM for help. You request to call RRT. She says no.
What is your next action?
Call RRT...anyone can call. even patients
Your patient is on Nepro tube feeding and having abdominal distention, nausea, vomiting, and abdominal pain. Which interventions are most appropriate at this time?
Sign of feeding intolerance
Stop the feed for one hour and reassess
What are nursing interventions for lung expansion in a patient with a chest tube?
Cough, deep breathe, ambulation, incentive spirometer.
What is the desired outcome for the aPTT when a patient is on a hearing drip?
therapeutic level
Per AdventHealt lift policy, you should not live more than ____ pounds. If you have to lift more than ___ pounds, you must use lift equipment.
5 pounds
These interventions will achieve what outcome: Blood cultures, lactic acid, antibiotics, start saline, take vitals
BLAST or 0-3 hour bundle
Treat sepsis
Your patient is NPO after midnight for an EGD. Medical history: DM
What is a possible complication for this patient, and how can we prevent it?
Hypoglycemia
Contact provider to obtain orders for dextrose gtt when anticipating NPO status >4hrs on diabetic patient.
Do NOT hang D10 without an order.
During BSH, the day nurses complained about how much food the patient eats. She states, "She eats Belvita biscuit cookies all day, like I mean ALL day!" The glucose at 1800 was 323 and was covered with Prandial and SSI.
At 1900, What is your immediate concern?
Hypoglycemia,
Eating carbs within 2 hours of an accucheck and >180-the provider needs to be notified.
Titrate this gtt in units/kg/hr, NOT ml/hr
What is a Heparin gtt?
True or False:
Is it a very good idea to review the last 24 hours' progress notes at the start of your shift to gain an understanding of your patient.
True
During your assessment, you notice a change in your patient.
Vital signs: 101F, 120, 120/80, 26, 99% RA
The patient reports increased SOB and a productive cough.
What is your concern?
Sepsis
You are caring for a patient with an NGT. The charge nurse askes you to verify placement at the start of your shift.
What interventions can achieve this outcome?
1. auscultate in the LUQ
2. Look at the measurement the previous nurse documented and the measurement at insertion
3. Aspirate GI contents
A patient post-op day 4 from a hip replacement is now showing signs of an SBO. The patient is now NPO pending CT results. You notice the accuchecks are ac&hs. What needs to be done now?
Change accuchecks to q 4 hours and notify the provider.
You are verifying PRBC with a nurse. You notice the rate is set at 25mL/hr.
What other information do you need to obtain?
The planned rate?
PRBC will need to be infused in less than 4 hours.
True or false:
If you do not complete mandatory education by the due date, will you receive a corrective action?
True, corrective actions will decrease your ability to transfer for up to one year.
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 concern?
Possible blood transfusion reaction
Stop the transfusion, assess, take vitals, and notify the provider.
Your patient has a PEG tube receiving TF at a rate of 45mL/hr. During BSH, the nurse reports GI WNL and proceeds to check gastric residual with you.
Should this be avoided in this situation?
Yes, gastric residual only when there are signs of feeding intolerance.
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 SSI.
What should be avoided in this situation?
Hold Prandial and give SSI
You started a blood transfusion at 0915. What time will you complete vital signs?
0915, 0930, 1015, 1115, 1215, 1315
True or false:
As a nurse in FL, you must join CE Broker before you renew your nursing license.
True.
CE Broker | Continuing Education Management
They will keep track of your CE and report it to the state.
You are caring for a patient on a heparin drip for bilateral PEs. The patient has no medical history. She is a stay-at-home mom with three kids. She started complaining of a "stress" headache, which she reports she gets all the time. You give her Tylenol. 1.5 hours later, the headache is the same.
What is your immediate concern?
Brain bleed...stat assessment and call the provider
What port should medications be administered through a GJ Tube?
Patient is NPO. Accu check every 4 hours.
Glucose 221.
SSI: >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 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
List one reason why BSH is so helpful!
If your patient dead?
Are you set up for failure? Pain, IV site, IVF, drains, potty
NEURO assessment!!!! NEURO assessment!!!!
Avoid mistakes by involving the patient
Great was to learn!!
Improves communication
Saves time by reducing need for clarification and streamlines transition of care