As you are talking with his wife you notice that she has sneezed a couple of times and has been coughing. What respiratory
hygiene/cough etiquette education should you provide?
a. Instruct the wife that she must leave the facility.
b. Provide tissues to the wife and educate regarding covering nose/mouth with tissue, disposing of tissue and then performing hand hygiene.
c. Consider having the wife wear a mask if the coughing and/or sneezing become worse .
d. Both B and C.
As part of orienting Mr. James and his wife to the clinic and exam
room, you educate them on clinic policies.
What key patient/family education should you share regarding hand hygiene?
a. Patient/family should only wash their hands when visibly soiled.
b. Family should perform hand hygiene using both soap and water as well as alcohol foam before entering patient room.
c. If patient is on contact isolation for C-Diff, family should perform hand hygiene only with alcohol foam when leaving the patient’s room.
d. Family should perform hand hygiene before any patient contact (e.g., before entering room, before/after assisting patient with ADLs, etc.).
*New Slide*
You get Mr. James settled into his exam room, take his vital signs and review his allergies
and current medications.
*New Slide*
When taking Mr. James’ blood pressure, you know that it is important to a. Use any adult size blood pressure cuffb. Use a large size adult blood pressure cuff forincreased accuracyc. Use a blood pressure cuff that covers 80% of the
circumference of the upper armd. Use a pediatric size blood pressure cuff if it is the only cuff available
Mr. James’ vital signs are as follows:• Temp – 39.5C
• HR – 82• RR – 18
• BP – 132/80
You assess the fever further and decide that he may need something to help bring the fever
down. You give report to the provider, inform them about the fever and ask for an order.
*Revised Slide*
Because the patient has difficulty swallowing tablets the provider enters an order for: Acetaminophen 650mg PO for
fever x 1 now for temp > 38.5C
You obtain a new bottle of Tylenol and label it appropriately after drawing up the
dose.
You are assessing Mr. James’ pain. Which pain scale should you use? (Click on the best response)
Assessment Sedation Normal Pain / Agitation
Criteria - 2 - 1 0 1 2
Crying I rritability
No cry with painful stimuli
Moans or cries minimally with painful stimuli
Appropriate crying Not irritable
Irritable or crying at intervals Consolable
High-pitched or silent-continuous cry Inconsolable
Behavior State
No arousal to any stimuli No spontaneous movement
Arouses minimally to stimuli
Little spontaneous movement
Appropriate for gestational age
Restless, squirming Awakens frequently
Arching, kicking Constantly awake or Arouses minimally / no movement (not sedated)
Facial Expression
Mouth is lax No expression
Minimal expression with stimuli
Relaxed Appropriate
Any pain expression intermittent
Any pain expression continual
Extremities Tone
No grasp reflex Flaccid tone
Weak grasp reflex
muscle tone
Relaxed hands and feet Normal tone
Intermittent clenched toes, fists or finger splay Body is not tense
Continual clenched toes, fists, or finger splay Body is tense
Vital Signs HR, RR, BP, SaO2
No variability with stimuli Hypoventilation or apnea
< 10% variability from baseline with stimuli
Within baseline or normal for gestational age
10-20% from baseline SaO2 76-85% with stimulation – quick recovery
> 20% from baseline SaO2 75% with stimulation – slow recovery Out of sync with vent
0 1 2 3 4 5 6 7 8 9 10No Pain
Worst Pain
Categories 0 1 2Face No
particular expression or smile
Occasional grimace or frown, withdrawn, disinterest
Frequent to constant frown, quivering chin, clenched jaw
Legs Normal position or relaxed
Uneasy, restless, tense Kicking or legs drawn up
Activity Lying quietly, normal position, moves easily
Squirming, shifting back and forth, tense
Arched, rigid, or jerking
Cry No cry (awake or asleep)
Moans or whimper; occasional complaint
Crying steadily, screams, or sobs, frequent complaints
Consoliability Content, relaxed
Reassured by occasional touching, hugging, or being talked to; distractible
Difficult to console or comfort
After assessment of Mr. James pain, the provider orders a dose of Morphine.
How do you determine if this is a high alert medication?
a. You note the medication label which identifies the medication as high alert.
b. Your check the MAR which will indicate special process for high alert medication.
c. You recall that any medication given as an IV infusion is considered High Alert.
d. You refer to the list of medications in the Nursing Process Standard “High Alert Medications Protocol” and the high alert drug list from pharmacy.
If it was Influenza season and Mr. James had an order for the Influenza Vaccine while in clinic, you would administer the vaccine a. Subcutaneous, using a 180 degree angle in the
deltoid b. Intramuscular, using a 90 degree angle in the vastus
lateralisc. Subcutaneous, using a 90 degree angle in the vastus
lateralisd. Intramuscular, using a 90 degree angle in the
deltoid
The provider tells you that he has now ordered a CXR and that the patient must go to radiology. You now have orders for Mr. James
to have completed before he goes down to radiology.
Zofran 8 mg IV for nausea x 1 now
You prepare the Zofran in a syringe to give to Mr. James. What information must be included on the
syringe that contains the medication?choose all that apply
One of the 6 Rights of Medication Administration is to verify the right patient.
How do we verify Right Patient in the ambulatory setting?
a. Name and history numberb. Name and addressc. Name and room number d. Name and date of birth
A Transporter has just arrived to take Mr.
James down to X-ray. You have completed the “Ticket to Ride”.
Mr. James arrives for his procedure. The staff performs a time-out. Which of the following statements about time-out are correct? Choose all that apply
a. Only the transporter and the receiving nurse perform the time-out.
b. All members of the procedure team perform the time-out.c. The right patient is verified.d. The right procedure is verified.e. The pre-procedure check-list is completed.f. Documentation by the proceduralist that time-out
occurred is included in the medical record.g. Time-out is not required for this procedure.
*New Slide*Mr. James has returned to clinic after his X-ray. You need to reassess his fever now that it has been over an hour since he received the dose of Tylenol ordered in clinic. You are busy with another sick patient in clinic and think about asking your co-worker to re-check Mr. James vital signs. Which of the following statements regarding delegation is true?
a. An unlicensed assistive personnel (i.e.. CMA, NCA) can delegate to another unlicensed assistive personnel.
b. A Registered Nurse can delegate any task to a CMA or NCA. c. An RN can delegate to a CMA or NCA only if the task is consistent with the
rules for delegation and the UAP is properly trained and competent. d. A CMA or NCA can not refuse a task that is delegated by an RN.
Mr. James is seen by the provider and given all of his test results. His fever
and nausea have resolved. You provide final patient education to Mr.
James and his wife.
*Revised Slide*
*New Slide*
In providing patient education to Mr. James and his wife you review with him his new prescriptions and home care instructions the doctor has ordered. In assuring that Mr. James understands the patient education you have provided, you know to a. Ask Mr. James to repeat back to you the instructions you
have given himb. Provide the number for the telephone triage line and on call
physicianc. Ask Mr. James and his wife if they have any questions and
provide them with written directionsd. All of the above