Nursing Role Basics

Question 1

What is medication reconciliation

Answer 1

When a run compares current and past meds

Question 2

When is medication reconciliation done?

Answer 2

At every transition in care
Ex: long term- hospital- long term
Floor- floor if new orders change

Question 3

What is the purpose of medication reconciliation?

Answer 3

Omissions
Duplications
Dosing
Interactions

Question 4

The 5 rights of delegation

Answer 4

Right person- consider experience
Right task
Right circumstances
Right direction & communication
Right supervision and evaluation

Question 5

If a pt is unstable, should a rn delegate?

Answer 5

No

Question 6

The rn should take which of the following pts

Answer 6

Unstable or potential to be unstable
Blood transfusions
Initial teaching
Feelings- if unstable or post cva 
Initial plan of care
Discharge

Question 7

What tasks are an lpn allowed to do?

Answer 7

Trach suction
Foley- insert and measure
Dressings
Culture / data collection
Stable pts
Re-I force teaching
Contribute to nsg care plan
Administers IVPB meds
Monitors IV meds

Question 8

Are lpn’s allowed to do sterile techniques?

Answer 8

Yes

Question 9

What tasks are AP’s allowed to do?

Answer 9

ADL's
VS's
Feeding
Bathing
Ambulating
Wt
I/o's 
Safety
Hygiene and grooming

Question 10

What is the difference bx actual and potential problems?

Answer 10

Actual problems are problems occurring now and must be cared for/ assessed FIRST!

Question 11

Mallows hierarchy of needs

Answer 11

Physiological
Safety
Love/belonging
Esteem
Self actualization

Question 12

What are the ABCS?

Answer 12

Airway
Breathing
Circulation
Safety

Question 13

What is the RN’s role in consent?

Answer 13

We act as the witness

Question 14

Types of consent

Answer 14

General- procedures and txs

Implied- life or limb, pt incapacitated , lifesaving situations

Question 15

Who is responsible for dosing med errors?

Answer 15

Pharmacy

Doctor and RN

Question 16

What is negligence/

Answer 16

The omission to do something

Question 17

What is malpractice

Answer 17

Failure of a professional person to act or do something

Question 18

Disaster tagging

Answer 18

Black- brain matter, severe head trauma, dilated pupils
Red- Immediate priority, breathing/ airway obstruction
Yellow- can wait a few hours too see( ex: fracture)
Green- walking wounded, (ex: sprains, fractures, general injuries)

Question 19

When is culturally competent care required?

Answer 19

Birth
Death/ end if life
Procedures
Communication 
Meds- herbs
Hygiene- shaving (particularly head)

Question 20

Assessing cultural / religious preferences

Answer 20

Is it safe

Is it something you can do

Question 21

In an emergent situation, if restraints are used, when does the order have to be signed?

Answer 21

Within 1 hour

Question 22

How often must pt be released from restraints?

Answer 22

Q2H:
ROM
Bathroom
Ambulate
Perfusion check
Tur and position

Question 23

How often are VS’s taken when restraints are used?

Answer 23

Q 15 min

Question 24

Seizure safety

Answer 24

Suction in room
Padded side rails
O2
Bed in lowest position
Meds (anticonvulsants)

Question 25

In-seizure protocol

Answer 25

``` Get pt into a safe position Clear the area Pt on their side Don't put anything into mouth Time seizure What did it look like? ```

Question 26

Post seizure protocol

Answer 26

Re-orient pt | Clean pt if incontinent

Question 27

Fire - RACE

Answer 27

Rescue Alarm Contain fire Extinguish

Question 28

What is brachytherapy

Answer 28

Sealed source of radiation

Question 29

Visitor rules for Brachytherapy

Answer 29

30 mins per day 6 ft No pregnancy / children

Question 30

Nursing rules for brachytherapy

Answer 30

``` Wear dosimeter badge Cluster care Use long tongs of dislodged Linens don't leave pt room- scanned Distance from pt - 6 ft ```

Question 31

When is trendelenburg C/I?

Answer 31

Brain swelling

Question 32

Crutches

Answer 32

6" in front and sides 3 fingers under axillary Wt should be bearing on hand bars, not axillary

Question 33

What is the first question of gaits?

Answer 33

Is it wt bearing or not?

Question 34

Which gait is non-wt bearing ?

Answer 34

3 pt gait

Question 35

Which gaits are partial/ wt bearing ?

Answer 35

2 and 4 pt gaits

Question 36

4 pt gait

Answer 36

Most stable | 4 individual separate steps

Question 37

2 pt gait

Answer 37

Wt bearing on both legs

Question 38

What is the difference bx 2 and 4 pt gait?

Answer 38

2 pt- crutch and leg moved at the same time

Question 39

Stair rules

Answer 39

Good leg goes up first | Bad leg goes down first

Question 40

Canes

Answer 40

- held on strong side - advance 6- 10" when walking - bad leg steps toward the cane initially

Question 41

What disinfectant kills viruses?

Answer 41

Bleach | NOT ALCOHOL

Question 42

Bleach: water ratio

Answer 42

1:10

Question 43

Semi-fowlers position

Answer 43

HOB > 30

Question 44

Fowlers position

Answer 44

HOB > 45

Question 45

High fowlers position

Answer 45

HOB > 90

Question 46

Supine position

Answer 46

Lying on back with head and shoulders propped up slightly with a pillow

Question 47

Prone position

Answer 47

Lying on abdomen with head turned to the side

Question 48

Lateral position

Answer 48

Side lying

Question 49

Sims position

Answer 49

Aka : semi prone | Lying on the left side with most wt anterior

Question 50

Trendelenburg position

Answer 50

Head and body lowered with ft elevated

Question 51

Modified trendelenburg

Answer 51

Supine with the legs elevated

Question 52

Reverse trendelenburg

Answer 52

Head elevated with ft lowered

Question 53

Dorsal recumbent position

Answer 53

Supine with knees flexed

Question 54

What situations do we use standard precautions?

Answer 54

Body fluids Non- intact skin Mucous membranes

Question 55

What situations do we use airborne precautions?

Answer 55

Measles Varicella TB

Question 56

PPE needed for airborn precautions

Answer 56

Standard PPE and N95 mask | Negative pressure room

Question 57

Situations for droplet precautions ?

Answer 57

``` Strep PNA Scarlet fever rubella Pertussis Mumps Meningococcal PNA/sepsis ```

Question 58

Droplet precautions

Answer 58

Standard PPE | Same room as pt with same org

Question 59

Situations for contact precautions

Answer 59

Wound drainage Fecal incontinence Bodily discharges

Question 60

Rules for pt leaving the room on isolation

Answer 60

Contact- cover the wound Droplet- pt wears mask Airborn- pt wears surgical mask

Question 61

Should you ever leave a pt alone?

Answer 61

NO

Question 62

DO WE GIVE BOLUSES OF H2O THROUGH THE NGT?

Answer 62

NO

Question 63

What is usually the earliest indicator that something is wrong?

Answer 63

Cardiac

Question 64

Pt's become a priority when they exhibit one or all of the following

Answer 64

D- disorientation A- Airway B- breathing C- Circulation

Question 65

When situation is not life threatening, what should the nurse do first?

Answer 65

ASSESS

Question 66

Name some examples of situations in which the nurse needs to act immediately before assessing

Answer 66

Compartment syndrome | Life endangering situations

Question 67

What are the 5 questions that should be asked when assessing priority patients (priority questions)

Answer 67

``` 1- acute or chronic 2- expected s/s or unexpected? 3- treated or untreated 4- lab values- normal or abnormal? 5- time sensitive? ```

Question 68

Which nurses get the most stable pts?

Answer 68

Floats New grads Fill ins

Question 69

Which surgical patients get priority?

Answer 69

Consider recovery time | Do they require more than one form of assistance ?

Question 70

What step is always last in priority?

Answer 70

Documentation

Question 71

When do we notify the provider?

Answer 71

Critical situations

Question 72

What should we did when a family expresses concern?

Answer 72

Screen the patient

Question 73

What are the priority actions after a pt falls?

Answer 73

Consciousness and vitals

Question 74

What is CAGE?

Answer 74

Screening for alcoholism

Question 75

What is the screening for CAGE?

Answer 75

C- cut down A- angry/ annoyed at others? G- guilt E- eye opener, need a fix when u first wake up

Question 76

What is one positive aspect of organ donation?

Answer 76

Helps grieving process- especially if a child dies

Question 77

How old does someone have to be to give informed consent?

Answer 77

17 Married Pregnant Emancipated

Question 78

When does a pt first get ambulated after surgery

Answer 78

Next shift or next day

Question 79

When should COPD pts rest?

Answer 79

In bx activities

Question 80

Older patients are always at risk for what with meds?

Answer 80

Toxicity

Question 81

What should be tried first before increasing or adding a pharm?

Answer 81

Non-pharm interventions

Question 82

In order to increase muscle strength, have the pt do what?

Answer 82

Encourage gross motor mvmt

Question 83

In order to increase coordination, encourage the pt to do what?

Answer 83

Encourage fine motor mvmt

Question 84

Incident reports

Answer 84

- internal document only - use only facts - Do Not mention in patient chart