Blood Products
Which compatibility test is mandatory before administering blood products?
Type and Cross
A nurse is caring for a pt with a subclavian central line. What is the priority nursing action if the line is occluded?
What does the second "R" stand for in SBARR
Read Back
Is this order complete?
500 mg Acetaminophen PO Q6H PRN for mild pain
Yes!
What are the 4 symptoms of SIRS criteria?
HR: greater than 90
Temp: < 96.8 or > than 101.0
RR: greater than 20
WBC count: <4,000 or >12,000
If a patients pre-transfusion temperature is 99.1 ... what is their target temp?
100.9
Which is the priority intervention when a central line malposition is suspected?
Request an x-ray to confirm placement
What do CUS words stand for?
I am CONCERNED
I am UNCOMFORTABLE
This is a SAFETY issue
What is wrong with this order?
50 mg Metoprolol tartrate QD
QD is not an acceptable abbreviation
What marks progression from SIRS to sepsis?
2 of the 4 criteria and a known or suspected infection
A nurse is preparing to begin a blood transfusion for a patinet whose blood type is A+. Please name all blood types that the patient may recieve.
O-, O+, A-, A+
What lab value is most critical to monitor during TPN therapy?
Blood glucose
What best describes this statement? "You should already know how to do this; I don’t have time to teach you."
Incivility
What is missing from this order?
10 Units Insulin Glargine SubQ
Frequency
If a patient is suspected to have sepsis, how should the nurse treat them?
Hint: Initial Bundles Treatment
1. IV fluid resucitation
2. Labs: lactate & procalcitonin levels
3. Blood cultures - 2 sets!
4. Broad Spectrum Antibiotic within 1 hr
The nurse started the blood transfusion 15 minutes ago. Upon reassessment, the patient reports an itchy rash on their lower back. What do you do?
STOP THE INFUSION
contact the provider
What is the best method to prevent catheter-related bloodstream infections (CLABSIs)?
Change the dressing weekly using sterile technique
Use chlorhexidine baths daily for hospitalized patient
What is an example of lateral violence in nursing?
A physician yelling at a family member for not complying with treatment
A nurse withholding critical information during shift-to-shift report
A patient hitting a nurse out of disorientation
A scheduler requiring an RN to float to an unfamiliar unit
A nurse withholding critical information during shift-to-shift report
Is this order complete?
2.0 mg Morphine IVP Q4H for moderate to severe pain
No
There should not be a trailing zero
pt presents w/HR 92, Temp 96.6, RR 24, & BP 88/54. Labs show WBC 14.6, lactic acid 4.5, procalcitonin 10, and UTI. Creatinine 2.4 (0.6-1.1), BUN 30 (7-20), and GFR 45 (>90). Pt has been given fluid bolus. What stage of sepsis is the patient in?
Severe Sepsis
Patient has met 2+ SIRS criteria, has a known or suspected infection, shows signs of organ failure, and continues to have a SBP <90 after fluid bolus
A client with heart failure is receiving a blood transfusion. What intervention can help prevent transfusion-associated circulatory overload (TACO)?
Decrease the initial transfusion rate (60 mL/hr)
During CVAD removal, the patient suddenly develops SOB and cyanosis. What is the priority nursing action?
Apply vaseline dressing immediately
Position the patient on their left side in Trendelenburg
Which approach is best for resolving team conflicts?
Using assertive and respectful communication to address concerns
What is missing in this order?
Furosemide 40 mg IV
Frequency
Indication (if PRN)
pt presents w/HR 92, Temp 101.1, RR 18, & BP 118/78. Labs show WBC 14.6, lactic acid 2.6, procalcitonin 2.2, and UTI. What stage of sepsis is the patient in?
Sepsis
Pt has met 2+ SIRS criteria, has a known or suspected infection, and shows signs of organ failure