Safety, Infx Control, Basic Patient Care

Day 1

If the radial pulse is no longer heard at 90mmHg, what should you inflate the cuff to?

120 mmHg

If pt’s potassium levels are high, think:

Apical pulse and rhythm

If lung sounds are diminished in the left lung, these are

Not normal sounds

Patient has reddened areas on the cheekbones. What should the nurse do?

Place padding around the cannula tubing

The patient’s O2 reading is improving with movement. What should the nurse do?

Place the nasal cannula in the nose securely

The patient’s O2 reading is coming up low. What should the nurse do first?

Verify the pulse ox placement

Where should oxygen chambers be stored?

In a cool area

What are the key points for fall prevention (inpatient)?

Hourly rounds, organize belongings (things within reach), position changes slow, and ensure sufficient lighting

What should you document when a patient is in restraints?

Why the pt is in restraints, mental status, time in restraints, and care offered

How long does a restraint order last before needing a new evaluation and order?

24 hours

Where should restraints be tied to?

The bed frame itself, but not the rails or headboard

When a patient is in restraints, what should the nurse do every 2 hours?

Vitals, ROM, skin integrity checks, and offer bathroom breaks

After applying restraints, what is the first thing to asses (and every 15 minutes after)?

Capillary refill

A patient has sleep apnea and is given a sedative. What should the nurse check?

Airway pressure device is on and in place.

What does urine specific gravity help identify?

Dehydration, kidney problem, or diabetes insipidus

What does urine specific gravity show?

Concentration of particles in urine

What is the normal range for urine specific gravity?

1.005 - 1.030

What does a high urine specific gravity indicate?

Dehydration, vomiting, diarrhea

What does a low urine specific gravity indicate?

Kidney damage, kidney failure

The patient has a pressure wound that shows red, intact skin. It is nonblanchable. What stage pressure ulcer is this?

Stage 1

The patient has a pressure wound that shows broken skin. Red, fleshy tissue is visible. What stage is this wound at?

Stage 2

The patient’s pressure ulcer has no skin showing. Yellow, fatty tissue is visible. What stage is the pressure wound at?

Stage 3

The patient has a pressure wound with visible bone and muscle tissue showing. What stage pressure wound is this?

Stage 4

The patient’s pressure wound has visible black tissue and slough, and you are unable to see past it. What stage pressure wound is this?

Unstageable

What PPE should be worn when working with MRSA patients?

Mask, gloves, gown

What increases risk for MRSA?

Weakened immune systems, extended hospital stays, surgeries

What are the symptoms of MRSA? What is a possibility of untreated MRSA?

Redness, swelling, drainage, abcess. Can cause sepsis

What are some possible treatments for MRSA?

Vancomycin, culture, topical abx, wound care, monitor WBCs (increase in WBCs = abx not working)

What are the accessory muscles that the body uses when it can’t breathe properly?

Sternocleidomastoid, neck (trapezius), intercostals, pectoralis major

What flexes during breathing?

Muscles outside the diaphragm

What counts as clear liquids?

Black coffee, water, ice, fruit juice with no pulp, sports drinks, carbonated drinks, gelatin, tea, clear broths, clear ice pops

For aspiration precautions, how should the patient be laying for oral if unconscious?

Side lying to prevent aspiraiton/liquid collecting at back of throat

Taking aspiration precautions, how should the patient be seated for feeding?

Lifted to 90 degrees

What should be observed during suctioning a patient with aspiration precautions?

Skin and membranes to watch for signs of respiratory distress

How should a patient be positioned to prevent liquids from pooling with aspiration precautions?

Upright

The UAP is assisting a patient with aspiration precautions. They have placed them at a 60 degree angle. What should the nurse do?

Correct them to place at 90 degrees to prevent aspiration.

What face mask is required for droplet precautions?

Surgical Mask

What are the common illnesses with droplet precautions?

Pertussis, influenza, meningitis, and pneumonia

What are the common illnesses with airborne precautions?

Measles, tuberculosis, and varicella

What are the two key precautions to take for droplets?

Surgical mask & goggles, and isolating the patient

What are the 4 key precautions to take for airborne illnesses?

N95 mask, negative pressure room, door closed, and patient wears surgical masks when in transport

What is the order of donning PPE?

Hand hygiene > gown > mask/respirator > goggles/face shield > gloves

What is the order of doffing PPE?

Gloves > goggle/faceshield > gown > mask/respirator > hand hygiene