Policies & Protocols
What must a patient have in place for an RN to legally pronounce them deceased?
A valid Do Not Resuscitate order
Which drain uses gravity to draw out fluid and is open-ended?
Penrose Drain
You receive a 12-lead EKG after a patient reports chest pain. How long do you have for provider interpretation?
10 minutes
When should you change the tubing on a continuous tube feed?
Every 24 hours
You have a patient that is cussing and hitting, being very aggressive. What code should you call if any?
Code Orange
How long does a nurse have to notify the provider after receiving a Sepsis Alert?
15 Mins
What type of central lines terminate in the Superior Vena Cava?
Internal Jugular Central Line, PICC, Dialysis Catheter
A patient complains of new-onset chest pain. What is your first action?
Call a Code Rapid
What should be done first if a patient has an IV infiltration?
Stop the infusion, disconnect tubing, and do not flush the line
What type of drain has a perforated rounded or flat drainage tube that is connected to a bulb device that creates a negative pressure while it expands
JP-Jackson- Pratt
What is the purpose of the guardrails in the drug library on IV infusion pumps?
To promote and provide safety limits for facility-defined medications
What supplies should always be present for a patient with a chest tube?
Vaseline gauze, sterile water, and tape
What should you NOT do if a Levophed infiltration occurs?
Apply pressure or keep the affected arm in a dependent position
What two questions should you always ask every patient, every time, before giving any medications?
Patient name and DOB
What type of patient would require a central line dressing change?
One with bloody drainage outside the CHG dressing
How often should a urinary needs assessment be completed for a patient with a Foley catheter?
Every Shift
What is a key sign that a central line dressing needs to be changed?
Bloody drainage outside the CHG dressing
A post-op patient reports moderate blood clots in their urinary drainage bag after a TURP. Is this concerning?
No, but no urine output for 1.5 hours is concerning
What should you do if your patient has an artificial limb and needs an MRI?
Notify the provider and imaging team before proceeding
What is the primary concern for a post-TURP patient?
No urine output for over 1.5 hours
What is the best prevention strategy for Hospital Acquired Conditions (HAC)?
Evaluating patients daily for unnecessary lines/tubes
A patient with a PICC line experiences a pinpoint amount of blood at the insertion site. Should the dressing be changed?
No, unless blood seeps outside the CHG dressing
Which patient should be assessed first at the beginning of a shift?
The patient with new onset chest pain and unknown BP
What is the primary difference between hemodialysis and peritoneal dialysis?
Hemodialysis uses a machine, while peritoneal dialysis utilizes the patient’s body
You had a patient fall. You must document post fall documentation in both Cerner and on paper. True or False?
TRUE