38 Questions
What should the reader do before administering any drug?
Check product information for changes and new information
What is required to be paid directly to CCC for internal or personal use?
$.10 per copy
What is the purpose of the Transactional Reporting Service?
To facilitate payment for photocopying
What is special about the pages of MedSurg Notes?
They are waterproof and reusable
What is the name of the company that grants permission for photocopying?
F.A.Davis Company
What is the feature of MedSurg Notes that allows users to erase old entries?
Alcohol pad
What should you do if you fail to document something?
Write another entry called “Addendum” to the note
What is delegation in nursing according to the National Council of State Boards of Nursing?
Transferring to a competent individual the authority to perform a selected nursing task in a selected situation
Which of the following tasks cannot be delegated?
Administering medications by direct IV bolus
Before delegating a task, what should you consider?
The complexity of the task and the potential for harm
What is one of the Five Rights of Delegation?
Right Task
Why is it important to consider the predictability of the outcome when delegating a task?
To assess the potential risks and harm
What should you consider when determining the problem-solving abilities required for a task?
The task's level of critical thinking required
What is the primary responsibility of the nurse when delegating a task?
To retain accountability for the delegation
What is the characteristic feature of hypoxemic respiratory failure?
PaO2 < 60 mm Hg
What should be done immediately upon assessing respiratory decline?
Notify physician or NP and respiratory therapist
What is the purpose of supplemental oxygen via nasal prongs or face mask?
To correct hypoxemia and keep oxygen saturation above 90%
What should be assessed in a focused assessment?
Oxygenation, lung sounds, respiratory rate, and work of breathing
What may be required in severe cases of hypoxemia?
Intubation and mechanical ventilation
What should be assessed during stabilizing and monitoring?
Cardiac monitor, BP, pulse oximetry, and ABG results
Why should oxygen be used cautiously in some patients?
In patients with severe COPD and chronic CO2 retention
What should be done if the patient is unable to clear secretions?
Suction if patient is unable to clear secretions
Who determines whether a nurse's care of a patient met the applicable standards of nursing care in a medical malpractice case?
A nursing expert
What is the purpose of documenting a patient's assessment findings, interventions, and triggers in urgent situations?
To enhance decision making and understand what happened, how it was handled, and what the outcomes were
What is essential to document when administering medication to a patient?
The time, route, and amount of medication administered
What should a nurse do if they do not get the response from the physician or nurse practitioner they think is required for the patient's best interests?
Call the nurse manager and report the problem
Why is it important to document as you go in urgent situations?
To establish a timeline for the incident and convey the interventions and outcomes accurately
What is the result of increased sophistication and complexity in nursing practice and medical technology?
An increase in the standards of nursing care
What is the purpose of documenting the response to medication or non-drug intervention?
To record the response to the medication and the time the response(s) occurred or the time you observed for a response
Why is it important to document the time you called the physician or nurse practitioner and their response?
To record the communication and response in case of a lawsuit
What should be assessed during the FOCUSED ASSESSMENT to evaluate oxygenation status?
Changes in mental status, chest pain, and SaO2
What should be asked during the FOCUSED ASSESSMENT to understand the patient's history of SOB?
About previous episodes of SOB, what provoked it, and if onset was sudden or gradual
What should be assessed during the FOCUSED ASSESSMENT to evaluate work of breathing?
Flared nostrils, retraction of subclavicular and intercostal spaces, use of accessory muscles, and orthopnea
What should be done during the STABILIZING AND MONITORING phase to support the patient's breathing?
Continuously monitor respiratory status
What should be done during the STABILIZING AND MONITORING phase to identify contributing factors?
Continue to assess the patient for underlying cause and contributing factors
What should be done during the STABILIZING AND MONITORING phase to prepare for potential interventions?
Obtain IV access and set up an O2 delivery system
What should be assessed during the FOCUSED ASSESSMENT to evaluate the patient's respiratory status?
All of the above
What should be done during the FOCUSED ASSESSMENT to evaluate the patient's cardiac status?
Evaluate cardiac rhythm and measure SaO2
Study Notes
Important Reminders
- Practice described in this book should be applied in accordance with professional standards of care, considering unique circumstances and product information.
- Caution is urged when using new or infrequently ordered drugs.
Documentation Guidelines for Urgent Situations
- Documentation is critical in urgent situations, enhancing decision-making and understanding of the situation.
- Document assessment findings, interventions, and triggers.
- Document as you go, establishing a timeline and conveying interventions and outcomes accurately.
- Record medication administration, response, and time.
- Document calls to physicians or nurse practitioners and their responses.
Delegation Guidelines
- Delegation is transferring authority to perform a selected nursing task in a specific situation, retaining accountability.
- Check state nurse practice acts for delegation details.
- Tasks that cannot be delegated include initial assessments, creating nursing plans, administering medications, and programming PCA pumps.
Five Rights of Delegation
- Right Task: Is the task within the caregiver's scope of practice?
- Right Person: Does the assigned caregiver have the required knowledge and skill?
- Right Circumstance: Is the task performed in the right situation?
- Right Direction: Are clear instructions provided?
- Right Supervision: Is adequate supervision available?
Focused Assessment
- Assess vital signs and respiratory status.
- Evaluate cardiovascular symptoms, oxygenation, and underlying respiratory conditions.
- Assess cough, work of breathing, and skin color.
- Auscultate lung fields, noting diminished breath sounds, crackles, wheezing, friction rubs, or stridor.
Stabilizing and Monitoring
- Continue to monitor respiratory status.
- Support efforts to breathe.
- Administer medications as ordered.
- Chart patient status and convey to physicians or nurse practitioners.
- Be prepared to obtain IV access, change or set up an O2 delivery system, assist with diagnostic testing, and more.
Abnormal ABG Results
- Hypoxemic respiratory failure: PaO2 < 60 mm Hg and normal or low PaCO2.
- Hypercapnic respiratory failure: PaCO2 > 50 mm Hg, associated with drug overdose, neuromuscular disease, chest wall abnormalities, and severe airway disorders.
- Seizures may occur with severe hypoxemia.
This quiz covers the guidelines for administering drugs, including checking product information for changes and new information on dosage and contraindications.
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