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Sunday Bloody Sunday - BPAM It Wasn't Me- Falls I'd Rather Have Nothing- C. Diff State of Confusion- Delirium/ CAM/ ACE unit My Heart Will Go On - Cardiac
100
What are 2 things you must do to fully complete a transfusion?
Document transfusion completed as "yes" and right click in pink header.
100
What is zeroing the bed and weigh your patient on admission?
How to ensure bed alarms activate properly for different-size patients.
100
What is stool characteristics for the lab to accept the specimen?
Liquid/loose stool that conforms to the specimen cup.
100
What are patients the CAM must be completed on?
65 or older, previous hx of delirium, prior hx of delirium with hospitalizations, & PRN.
100
What do you do with a patient experiencing chest pain?
STAT EKG
200
What is the time you must stay with the patient once the transfusion begins?
For the first 15 Minutes.
200
What is the distance between you and the patient while toileting in the bathroom or bedside commode?
Within arm's reach.
200
What are the initial steps when a patient has the first unexplained loose/liquid stool?
Document amount and characteristics in H/C, place patient on Contact + isolation, document under critical alerts "other", and notify the doctor.
200
When does CAM assessment need to be documented?
Document twice a day, day and evening shift & PRN
200
What is always notify the physician of rhythm change?
Your patient has a hx of A-fib, has been in NSR, and now has new onset A-fib.
300
What is the three pre-transfusion verification options you must document for ALL blood products?
The Appropriate Consents, Blood Products, Patient 2 ID's.
300
What are fall risk factors?
Recent fall within 1 year, delirium, weakness, stroke, syncope, orthostatic changes, surgical procedures, CNS effecting meds.
300
What is disposable items for an isolation room which must be removed when a patient is discharged?
Stethoscope, BP Cuff, thermometer, pulse oximeter finger probe, & pill crusher.
300
What is how to accurately perform the CAM?
Answer all questions and use standardized question prompts listed in H/C.
300
What is the nurses responsibility during their shift.
Verify your patient's tele strips from the Monitor Tech within the first 2 hours of our shift.
400
What is the window of time you must document "yes" or "no" to transfusion reaction?
Within 15 minutes of transfusion start.
400
What are ways to check patient's current mobility status and progress?
PLOF, CLOF, recent pain medication, balance, strength, ability to follow commands, and sign on patient's wall.
400
What is explained loose stool definitions?
Colon or small bowel surgery, new tube feed start, bowel prep, laxative, & enema.
400
What is inclusion criteria for the ACE unit?
75 and older, ambulatory @ baseline & medical diagnosis.
400
What is check the order in the PER for transport status?
How you know if you need to transport your patient on a monitor to a procedure, accompanied by a tele nurse.
500
What are PRBCs, FFP, & Platelets, with EVERY unit given.
These blood products need pre-transfusion verification, this often.
500
What is where do you easily find the PLOF?
It's in the HealthConnect Brain.
500
What must be included when sending 3rd liquid/loose stool to the lab?
Checklist filled out and signed by ANM.
500
What is exclusion criteria for the ACE unit?
Tele monitoring, Stroke/TIA, Isolation precautions, ETOH abuse/withdrawal, *active delirium, with disruptive behavior, *Dementia with behavioral problems/non redirectable, *1:1 sitter, long term care or placement issue, or comfort care.
500
What is when you call RRT and anticipate a heart alert?
Patient is clammy, pale, and c/o "bad heartburn". HR 120. Twelve lead EKG shows new left bundle branch block.




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