After I delegate a task, I am no longer responsible for any consequences that follow.

All of the following are the five rights of delegation except for:

-Right task

-Right time

-Right circumstance

-Right person

-Right medication

-Right assessment

-Right communication

-Right Supervision

Terrific Care Promotes Client Safety stands for...

Which of the following are rights of delegation?

Which of the following are delegable tasks to a qualified LPN?

Which of the following are delegable tasks to a qualified UAP?

Tasks can be delegated if the client is unstable as long as it is supervised.

Never delegate what you can...

The registered nurse (RN) is caring for a client with chronic obstructive pulmonary disease (COPD). Which intervention is

Appropriate for the RN to delegate to an unlicensed assistive personnel (UAP)?

A. Evaluate patient’s ability to cough effectively.

B. Assist patient to sitting position on the side of the bed.

C. Listen to breath sounds every 4-hours

D. Instruct the patient on use incentive spirometer.

The nurse is caring for a client who has cirrhosis of the liver and has had multiple episodes of sticky black stool and hematemesis. Client reports nausea, weakness, and dizziness. Extremities are cool to touch and capillary refill is sluggish. Vital signs: T 94.l F, HR 126, RR 28, BP 84/44, SpO2 88% on room air.

Which of the following actions are appropriate to delegate?

Can the following tasks be delegated or must they be carried out by the RN?

-Administer IV push medication

-Review glucose results for patients needing insulin

-Give preop report to the operating room

-Administer packed red blood cell transfusion

Can the following tasks be delegated or must they be carried out by the RN?

-Administer oral meds to stable patients

-Reinforce education that was previously taught

Can the following tasks be delegated or must they be carried out by the RN?

-Pass meal trays to stable patients

-Collect intake and output data

-Assist patients with toileting and hygiene

-Obtain vital signs on stable patients

Which of the following are purposes of the nursing care plan?

Which of the following are some disadvantages of standardized care plans?

Types of care plans include:

Case Study: Afternoon in the E.R. An accidental poisoning at a local warehouse has resulted in several patients being admitted with a range of symptoms. In which order should the nurse see the following clients?

Client 1: LOC is diminished and Gurgling heard when auscultating Lung sounds

Client 2: Having SOB, difficulty speaking and Intercostal retractions seen on assessment.

Client 3: Skin cool and clammy, and client is tachycardic

Which level of prioritizing care levels is described below?

-airway, breathing, circulation, VS changes/concerns

Which level of prioritizing care levels is described below?

Mental Status Changes, Acute Pain, Acute Urinary Elimination Problems, Untreated Medical Problem Requiring Immediate Attention, Abnormal Lab Values, Risks of Infection, Safety or Security

Which prioritizing care level is described below?

Lack of Knowledge, Coping, Family Coping, Activity, Rest

For each scenario, determine whether the following conditions would be considered critical, urgent, or non-urgent.

Chronic pain, Radiating chest pain, Deformed fracture with edema

For each scenario, determine whether the following conditions would be considered critical, urgent, or non-urgent.

Minor cut-needs stiches, sudden headache-blurry vision, severe allergic reaction

For each scenario, determine whether the following conditions would be considered critical, urgent, or non-urgent.

-Unconscious, pulseless

-Nondisplaced fracture

-Change in LOC

When considering only one patient, a useful prioritization strategy includes

The following is which level of priority for your client?

-SOB, uncontrolled pain, altered LOC, anxiety

Which level of prioritization is described?

-it has a high probability of harm (infection risk, falls)

Which level of prioritization is described?

-Keeps patient from moving to the next phase of wellness, it delays a patient's discharge

Mrs. Right is an 87-y/o with a 3-day history of GI disturbance. She presented to the emergency department with dehydration, flank pain, and a fever related to urosepsis. IV access was obtained and she has now been admitted to your floor. Cognition is reportedly baseline.

You are the nurse assigned to Mrs. Right, and you receive the following orders:

• Acetaminophen 650 mg po, every 6 hours as needed for pain or fever

• Ceftriaxone 1 g IVPB, administer after blood and urine cultures obtained

• Morphine 2 mg IV push every 2 hours PRN for moderate to severe pain

• Collect and send aerobic and anaerobic blood cultures

• Collect urine for culture and urinalysis

• 0.9% NS bolus, 1000 mL administered over 4 hours

Which of these orders should be implemented first? What is your rationale?

____ Check MAR for medication administration times for all of your patients

____ Take bedside report from night shift between 0700-0730.

____ Perform Safety Checks and introduce yourself to patients.

____ Hang four IV medications that are all due at 0900.

____ Give 0845 pre-op report on patient who’s going to surgery at 0900.

____ Pass the 0830 breakfast trays.

____ In-depth review of charts for the patients who are new to you.

____ Check 0600 glucose results for patients who need 0730 insulin

____ Administer 0900 pre-operative antibiotic to surgery patient

Prioritize the following list of tasks that will need to be accomplished as you begin your shift. Use a “1” for the first thing you will do, and a “10” for the last.

Perfusion depends on proper function of the cardiovascular system.

The nurse is reviewing the concept of perfusion. Which circulatory systems does the nurse know to be crucial to tissue perfusion?

Select all that apply.

A. Coronary Circulation

B. Cerebral Circulation

C. Systemic Circulation

D. Peripheral Circulation

E. Pulmonary Circulation

F. Renal Circulation

The nurse is assessing a patient’s heart sounds and recognizes that the S1 sound occurs at the beginning of ___1___ , defined as ___2___ of the ventricles. S1 is heard due to the closing of the ____3____ valves.

Blank #1 : Systole or Diastole?

Blank #2 : Filling or Contraction?

Blank #3 : Atrioventricular or Semilunar?

Which of the following manifestations of decreased cardiac output will consider your pt unstable?

Which of the following are manifestations of decreased cardiac output?

WHAT ARE SOME FACTORS THAT AFFECT HEART RATE?

Stroke volume is affected by three main factors:

Blood volume in ventricles at end of diastole

A stronger contraction gets better output

Resistance the ventricle must overcome

The greater the afterload, the greater the cardiac workload

Perfusion is affected by:

Factors affecting stroke volume:

Factors affecting heart rate:

The exchange of water, oxygen, electrolytes, nutrients, wastes, small proteins, and hormones are all completed at the...

Which of the following are NOT a sign of poor perfusion?

-pain, pallor, pulselessness, pneumonia, poor mobility, paraesthesia, paralysis, poikilothermia

We must consider both the ____ and ________ when assessing perfusion.

Cardiac cells have the following characteristics:

Cardiac cells ability to repeatedly initiate impulses without an outside stimulus

Cardiac cells ability to respond to stimulus and initiate an impulse

Cardiac cells ability to transmit the impulse along cell membranes

When muscle fiber in the cardiac cells shortens in response to a stimulus

When the cardiac cells muscle fiber is unable to respond to another stimulus during an interval following contraction

What is the conduction pathway of the heart?

Which is the normal pacemaker of the heart:

60-100 bpm

Which of the following pacemakers is 40-60 bpm

Which of the following pacemakers is 20-40 beats per minute

An EKG has a ______ view from negative lead to positive lead

Which of the following represents one cardiac cycle on an EKG?

Atrial depolarization (contraction)

Ventricular depolarization

Ventricular repolarization (reset)

The extent to which a cell can respond to a stimulus

Onset of QRS complex to approximately the peak of T wave

• Cardiac cells are fully depolarized and cannot be stimulated to conduct any additional electrical

impulse, no matter how strong the stimulus

Corresponds with the downslope of the T wave

• Cardiac cells are only partially full of electricity.

• Cells can be stimulated to depolarize if the electrical stimulus is strong enough

• Patient at high risk for lethal rhythms if another stimulus occurs

What is the most dangerous part of the cardiac cycle

-heart is only partially reset, so it can malfunction if stimulated there

EKG paper divided into small and big squares:

Small square = _._ seconds

Big square = __ seconds

What are the five steps to interpreting EKG rhythm strips

If the R-to-R intervals vary by less than 0.06 seconds (1.5 small boxes), the rhythm is considered

If the intervals vary by more than 0.06 seconds (1.5 small boxes), the rhythm is

represents the SA node firing at regular intervals (referred to as a sinus rhythm)

• First deviation from the isoelectric line

• Should be rounded and upright

Measures time from start of atrial contraction to start of ventricular contraction

• Measured from start of P wave to start of the QRS complex

Normal PR interval is

Which of the following represents the PR interval

complex represents depolarization (contraction) of the ventricles

First negative (downward) deflection of this large complex

First upward (positive) deflection after the P wave

The sharp, negative deflection that follows the R wave

Normal interval for QRS Complex is

When interpreting EKG rhythm strips, what do we assess about the P-wave?

Produced by ventricular repolarization (relaxation or reset)

-Commonly seen as the first upward or positive deflection following the QRS complex

-Not part of the 5 steps, but can give us some information

ECG waveforms from sources outside the heart Interference is seen on the monitor or ECG strip

Causes:

-Patient movement (most common)

-Loose or defective electrodes (fuzzy baseline)

-Improper grounding (60 cycle interference)

-Faulty ECG apparatus

Rhythms that originate in the SA node

Common variations of a sinus rhythm include:

Normal cardiac impulses start at sinoatrial node and are transmitted through the atria and down to the ventricles.

Starts at the SA node but is unusually slow (less than 60 bpm).

Sinus bradycardia is a normal variation in:

Which of the following are possible causes of bradycardia?

Which of the following are signs and symptoms of sinus bradycardia?

Which of the following are risks of sinus bradycardia?

Which of the following are nursing interventions for sinus bradycardia?

What are the medical treatments of sinus bradycardia?

faster than normal heartbeat related to a rapid firing of the sinoatrial (SA) node

Which of the following are causes of sinus tachycardia?

Which of the following are risks of sinus tachycardia?

Which of the following are nursing interventions for sinus tachycardia?

Which of the following are possible treatments for sinus tachycardia?

irregular impulse from the sinoatrial node.

• The rate usually increases with inspiration and decreases with expiration

What are the causes of sinus arrhythmia?

Signs and symptoms of sinus arrhythmia?

What is the treatment of sinus arrhythmia?

Ventricular standstill

• No electrical activity

• No cardiac output

• No perfusion

Which of the following are causes of asystole?

What are signs and symptoms of asystole?

Your patient suddenly becomes asystolic. You enter their room and note that they do not have a DNR. What is your next step?

Your patient just received an EKG. Based on the image, how do you interpret the rhythm?

Your patient's EKG is displayed. How would you interpret this rhythm?

Your pt EKG is displayed. How will you treat this pt?

Your pt's EKG is displayed. What is their rhythm interpretation?

The nurse is aware that stroke volume can be affected by which factors?

The nurse is performing a cardiovascular assessment on a patient and is aware that which factor can affect heart rate?

The nurse is assessing a patient's perfusion status and recognizes that cardiac output has a direct effect on perfusion. Which manifestations would be present in a patient with decreased cardiac output?

The nurse is aware that the T wave on the EKG represents what?

The nurse is aware that an electrocardiogram measures what?

The nurse is interpreting the EKG rhythm for a patient and is aware that the most important next step is what?

The nurse is assessing the perfusion status of a patient and is aware that which manifestations indicate altered perfusion?

The nurse is aware that the QRS complex on an ECG represents what?

The nurse is aware that the P wave on an EKG represents