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Funds Post Assessment Review (ASSURED A)

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Funds Post Assessment Review (ASSURED A) 1. List the pertinent information that should be included in a transfer report. a. Medical dx, care providers, demographics, overview of health status, plan of care, & recent progress, alterations that may precipitate an immediate concern, notification of assessment or care essentials w/i next few hours, most recent vitals, medications, diet, and activity orders, allergies, specific equipment or adaptive devices, advanced directives, emergency code status, family involvement in care, and health proxy if applicable. 2. *Please describe the five rights of delegation including an example of each: a. Right person b. Right task c. Right circumstance d. Right direction and communication e. Right supervision and evaluation 3. What are three (3) of the provider’s responsibility for obtaining an informed consent? a. Provides pt. with reason of treatment/procedure b. Teach pt. how treatment will benefit client c. Teach about risk involved 4. List three (3) actions to take during the analysis or data collection step. a. Recognize patterns or trends, b. Compare the data with expected standards or reference ranges c. Arrive at the conclusions to guide nursing care 5. The nurse discovers a fire on the unit. After following the proper steps included in RACE, the nurse begins to extinguish the fire. What is RACE? What are the proper steps for using a fire extinguisher? a. R- rescue, A- activate alarm, C- contain fire, E- extinguish and evacuate b. P- pull pin, A- aim at base of fire, S- squeeze handle, S- sweep extinguisher from side to side 6. A nurse is caring for an older adult client with dementia. What preventative measures should the nurse institute to reduce the risk of falls? a. Fall risk assessment b. Call light and personal belongings within reach c. Adequate lighting d. Orient to setting e. Room near nurses station f. Nonskid footwear g. No clutter, CLEAN room h. Assistive devices if needed i. Bed in low position 7. A nurse is providing discharge education to a client regarding home wound care. What manifestations of wound infection should the nurse include in this education? a. Fever, chills, foul odor, purulent drainage, redness, swelling 8. List at least five (5) priority considerations when performing a sterile dressing change. a. Avoid coughing, sneezing, and talking directly over sterile field b. Only dry, sterile items touch the field (1-inch border is non-sterile)c. Keep all objects above waist and within vision (do not turn back on field) d. Wash hands and don sterile gloves e. Hold items to add to sterile field at a min. of 6 inches above field 9. Identify three (3) priority-teaching points to include when educating a client to use a cane. a. Maintain two points of support on the ground at all times b. Keep cane on stronger side c. Move came forward then weaker leg 10. A nurse is caring for a client receiving oxygen therapy. What is the expected reference range when obtaining oxygen saturation level? Identify four (4) reasons the reference range may be lower. a. 95%-10% i. Increased work of breathing ii. Coughing iii. Wheezing iv. Cyanosis

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