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SCIP- no disposable razors (use electric razor& start ABX one hr before surgery)77. PICC line or triple lumen- flush with 10ml NS78. Further teaching for fiscally responsibility- letting family help (not a part of fiscally responsibility) 79. Lateral violence means bulling where other person gets offended80. Spontaneous birth- clear nasopharynx81. PACU following regional anesthesia- take vitals82. LPN- no central lines
83. Late deceleration (POOF; LION)84. Kawasaki- give immunoglobulins85. Avoid decongestants with BPH86. OT- fine motor skills/ PT- mobility87. Rotate peg tube 360 degrees88. Perform ADLs in am for rheumatoid arthritis89. Barium enema- clay colored stool90. Trach care- replace with new ties before remove the old ones91. Macular degeneration- Central vision loss92. Latex allergy- spina bifida/ multiple surgeries93. Foot drop patient in high top shoes, assess pressure points94. Liver enzymes- check statin use (give statins @night)95. Suicide risk- native American with gun permir- OUR test- old man that wife died96. Bacterial meningitis- mask when outside the room97. Colonoscopy- age 50, then Q10YR, prostate-Q1YR with digital exam98. Lispo-onset in 15-30min99. No ace inhibitors with K+ sparing diuretics100. Lost dentures- incident report101. Left CVA- establish means of communication. 102. HPV- give ages from 9-26103. D/C for disease- tonsillectomy104. Novice nurse gets DVT waiting for ultrasound105. Question with vital signs and low K+do EKG first106. MS patient should not take hot bath107. Priority- patient with internal radiation has visitor >2hours108. LPN can recheck liver biopsy vital signs109. Testicular exam after hot bath/ shower110. Alcohol based rub before putting gloves for standard precautions111. Post-op priority- pacemaker feeling dizzy112. PRBC- do not flush with D5W113. Dying kid- comfortable measures114. Patient with insomnia- do activities in AM115. Respiratory alkalosis for hyperventilation116. Correct technique- diaphragm of stethoscope to hear bronchovesicular sounds117. Sanguineous to serosanguinous drainage= wound healing118. TORB (telephone order read back)119. Patient with potassium 2.4- do not get patient OOB120. Emphysema-inhaler before exercise121. Administering eye gel- from nose outward122. Priority patient in mom/ baby unit-neonate with HR of 95123. Needs additional teaching about informed consent- signed by nurses to indicate patient understanding124. Order of action- assess, plan, communicate, surveillance/supervise, evaluate/feedback125. Priority patient- 2hr post lumbar puncture reports headache
126. Restraints for violent behavior- one to one monitoring127. Further seat belt safety teaching- 11-year-old sitting in front seat128. 4 year old on ABX- hold vaccines for 2 weeks129. Patient complaining of abdominal cramping during soap suds enema- lower bag130. Signs of hypothyroidism- dry skin, menorrhagia, and brittle nails131. Appropriate IM needle gauge and size- 25 gauge 1’ needle132. Glargine- do not mix133. Magnesium toxicity- decrease urine output134. Patient’s aPTT while on Heparin is 30sec- increase Heparin135. Patient scheduled for CT has creatinine of 1.8- notify HCP136. Medication treatment for open-angle glaucoma- Timolol (hold if HR <60)