Tools, Risks, Questions, Oh my
Which tool predicts ulcer risk?
What is Braden Scale?
Which of the following is correct in documenting every day?
A. Q.D.
B. q1d
C. Daily
D. qd
What is C?
Patient weighs 286 lbs, how many kgs?
What is 130 kgs?
What is included in the S for SBAR?
What is the proper pattern for palpation of breasts?
What is vertical strip pattern of palpation?
What are the two biggest risks that a nurse has to assess for in an older adult?
What are fall and dysphagia risk?
What does SBAR stand for?
What is Situation, Background, Assessment, Recommendation?
Calculate intake:
1 8 oz glass of water
250 mL IV fluid
What is 490 mL?
What is included in the B in SBAR?
What is patient history, medications, vital signs, lab results, code status, signs and symptoms?
What positions do you place the patient in for a breast and axillae exam?
What is supine with arms raised over head, sitting up and hands on hips leaning forward, and raising relaxed arm?
When assessing an older adult, what assessment tool should the nurse use for quick cognitive evaluation?
What is mental status examination (MSE)?
Which of the following would cause the charge nurse to intervene?
A. Graduate nurse is documenting skin assessment with another nurse
B. Graduate nurse gives login information to another graduate nurse to document the skin assessment
C. The graduate nurse logs out of patient's chart before leaving a patient's room
What is B?
Calculate output:
Voided: 120 mL
Voided: 200 mL
Voided: 400 mL
1 large BM
What is 720 mL and 1 BM?
What is included in the R in SBAR?
What is what you want, how to proceed, readback of orders received?
If you feel a lump or mass, what do you document?
What is location, size, shape, consistency, movable, distinctness, nipple, skin over lump, tenderness, lymphedema?
When assessing an older adult, what two components are added to the health history questionnaire for the patient's ability?
What are ADLs and IADLs?
How should the nurse conduct a patient interview?
What is be prepared prior to entering room, speak clearly with proper pronunciation, ensure privacy and environment free of distractions (if you can), use open-ended questions to obtain adequate medical information?
Calculate intake:
2 8 oz glasses of water
1 20 oz coke
2 4 oz cups of chicken broth
4 4 oz jellos
What is 1800 mL?
What is included in the A in SBAR?
What is what you think the key underlying problem/concern is, key changes in assessments such as vitals, neurologic, respiratory, cardiac, GI, GU, musculoskeletal, skin, nutrition, mentation, ADL, transfer, safety, environmental changes?
What unexpected findings should the nurse educate a patient to report?
What is dimpling, edema, fixation, deviation in nipple pointing, inflammation, erythema, and lumps/masses?
What is the correct medical abbreviation/documentation for the following?
twice a day, body mass index, three times a day, as needed, before meals and at bedtime
What is BID, BMI, TID, PRN, and ACHS?
Calculate Intake and Output, report findings.
250 mL IV antibiotic, 300 mL urine, 975 mL IV fluid, 4- 4 oz soups, 4- 12 oz water, 500 mL urine, 75 mL JP drain, vomit 400 mL, 1- 4 oz jello
What is intake 3265 mL; output 1275 mL?
Patient has fluid balance excess.
Tell me an SBAR--Patient: John Doe, DOB 1/1/1958, Room 212 on surgical unit. Patient is pale and sweaty, feels confused and weak with chest pain, has history of HTN, admitted for GI bleed, hemoglobin at 0600 was 9.0, he has had two small bloody BM in the last hour. Vitals 90/50, pulse 110, T 97.1F orally, R 24, O2 sat 95% on room air.
What is: Situation: Dr. Jones, this is Jane Smith calling from the surgical unit. I have Mr. Doe in room 212, DOB 1/1/1958. He is pale, sweaty, reports that he feels confused and weak, complains of chest pain.
Background: Patient has history of HTN, was admitted for GI bleed. His last hemoglobin at 0600 was 9.0. He has had two small bloody BMs in the last hour. Vitals 90/50, pulse 110, T 97.1, R 24, O2 sat 95% on room air.
Assessment: I think he has an active GI bleed, but we can't rule out an MI. We do not have recent cardiac enzymes or an updated H&H.
Recommendation: I would like you to evaluate him right away and get an EKG and updated labs stat.
How should the nurse educate a patient to perform a breast self exam?
What is perform right after menstrual period (day 4-7) of cycle or same time of month, palpate in shower and lying supine, using the vertical strip pattern with three stages of palpation (touch, light palpation, deep palpation)?