FY 15: ICU Annual Policy / Procedure Review

1. This facilities' organ procurment agency is:

Life Point

Death Star

SCOPA

LOPA

per CPM 00- 14 - 16, ORGAN AND TISSUE DONOR PROGRAM

Explanation

per CPM 00- 14 - 16, ORGAN AND TISSUE DONOR PROGRAM

2. According to the Medication Reconcilliation CPM, what is the ICU's nurses' role?

Nothing, that's the pharmacist's job

Nothing, that's the MD's job

Reinforce medication teaching & documenting it in the Pt -Family Education Note

What's med rec?

per CPM 11-12-23, Medication Reconcilliation

The Registered Nurse will complete the nursing portion of the Discharge Instructions template and will reinforce the medications and other instructions with the patient prior to discharge. A copy of the discharge instructions, which includes complete and reconciled list of the patient’s medications, is provided directly to the patient, and the patient’s family as needed and the list is explained to the patient and/or family.

Explanation

per CPM 11-12-23, Medication Reconcilliation

The Registered Nurse will complete the nursing portion of the Discharge Instructions template and will reinforce the medications and other instructions with the patient prior to discharge. A copy of the discharge instructions, which includes complete and reconciled list of the patient’s medications, is provided directly to the patient, and the patient’s family as needed and the list is explained to the patient and/or family.

3. Because this is the ICU and all our patients are HIGH RISK FOR FALLS, we do not need to document fall prevention interventions.

True

False

per CPM 118-13-18, ASSESSMENT AND CARE OF PATIENTS/RESIDENTS AT RISK OF FALLING

All patients in the ICU are identified as high fall risks due to medications, numerous invasive lines and critical condition. All ICU patients will be assessed on admission and prior to transfer to another unit.
Interventions: All staff will implement interventions to create a safe environment and maintain the safety of all patients

Explanation

per CPM 118-13-18, ASSESSMENT AND CARE OF PATIENTS/RESIDENTS AT RISK OF FALLING

All patients in the ICU are identified as high fall risks due to medications, numerous invasive lines and critical condition. All ICU patients will be assessed on admission and prior to transfer to another unit.
Interventions: All staff will implement interventions to create a safe environment and maintain the safety of all patients

4. Spinal Cord Injury (SCI) patients with an injury at T6 or above is at risk for autonaumic dysreflexia (AD). What is AD?

A skin disease

A hypertensive crisis / medical emergency caused by a noxious stimuli below the level of injury

A contracture that occurs from a mal-adaptive fitting to a wheel chair

This is the VA, we can cure SCI

per Spinal Cord Injury Treatment Guideline for Nurses and Physicians

Explanation

per Spinal Cord Injury Treatment Guideline for Nurses and Physicians

5. This facilities' organ procurment agency is:

Life Point

Death Star

SCOPA

LOPA

per CPM 00- 14 - 16, ORGAN AND TISSUE DONOR PROGRAM

Explanation

per CPM 00- 14 - 16, ORGAN AND TISSUE DONOR PROGRAM

6. Labeling blood tubes at the nurses' station is the proper place for this action.

True

False

per CPM 118-14-23, PATIENT IDENTIFICATION

Explanation

per CPM 118-14-23, PATIENT IDENTIFICATION

7. When asking a patient about suicide risk, the nurse should ask what? [CHECK ALL THAT APPLY]

Do you have thoughts of hurting yourself?

Do you have a plan?

What is the plan? (assertain if it is doable)

What did you have for lunch today?

CPM 116-13-03, SUICIDAL PRECAUTIONS

Explanation

CPM 116-13-03, SUICIDAL PRECAUTIONS

Submit

8. According to the ORDERING AND REPORTING TEST RESULTS CPM, if the nurse takes a critical lab value from the lab, then the nurse will use what procedure?

Nurses never take critical lab reports

Put the Lab on HOLD until the MD can be tracked down and told personally

Write the lab value on a paper towel and tell the PCC to call the MD

per CPM 11-14-01, ORDERING AND REPORTING TEST RESULTS.

Explanation

per CPM 11-14-01, ORDERING AND REPORTING TEST RESULTS.

9. Check below the types of patients who are at risk for aspiration and should be made NPO until evaluated by the speech pathologist: [CHECK ALL THAT APPLY]

A patient experiencing a TIA / CVA

A patient who was recently extubated after a long period of time

A patient who is drooling after putting food in their mouth

A patient who AAOx3

per CPM 112-11-07, MANAGEMENT OF PATIENTS WITH SWALLOWING (DYSPHAGIA) OR FEEDING DISORDERS &
Mosby's nursing procedures for Dysphagia as well as Aspiration Precautions

Explanation

per CPM 112-11-07, MANAGEMENT OF PATIENTS WITH SWALLOWING (DYSPHAGIA) OR FEEDING DISORDERS &
Mosby's nursing procedures for Dysphagia as well as Aspiration Precautions

Submit

10. Every effort will be made communicate with hearing impaired Veterans and non–English speaking family members to assure Veterans are afforded every available treatment and service to which they are entitled. This Medical Center will be properly equipped with TTY telephones to communicate effectively with hearing impaired Veterans and request sign interpreters when necessary. Non-English speaking individuals, generally Veterans' family members or persons acting on their behalf, will be offered the services of a language interpreter when necessary. What's a nurse to do to get this assistance to this patient / family?

Change the assignment - surely the new nurse learned this in orientation

Look up the CPM for COMMUNICATION WITH HEARING IMPAIRED/NON-ENGLISH SPEAKING INDIVIDUALS

Intubate the patient so they can't speak

Use a picture boad

per CPM 136-12-02, COMMUNICATION WITH HEARING IMPAIRED/NON-ENGLISH SPEAKING INDIVIDUALS

Explanation

per CPM 136-12-02, COMMUNICATION WITH HEARING IMPAIRED/NON-ENGLISH SPEAKING INDIVIDUALS

11. When completing the admission assessment - PRESSURE ULCER SECTION - if a score of less than 18 is tallied, then

Interventions must be docuemented in the Admission Assessment flow sheet

Move on to the next section

Pressure ulcers do not exist in unit

Write an incident report

If a score of less than 18 is tallied in the pressure ulcer section of the admission assessment, it means that there is a risk or presence of pressure ulcers in the patient. Therefore, interventions must be documented in the Admission Assessment flow sheet to address and prevent the development or worsening of pressure ulcers. This ensures that appropriate measures are taken to provide the necessary care and treatment for the patient's condition.

Explanation

If a score of less than 18 is tallied in the pressure ulcer section of the admission assessment, it means that there is a risk or presence of pressure ulcers in the patient. Therefore, interventions must be documented in the Admission Assessment flow sheet to address and prevent the development or worsening of pressure ulcers. This ensures that appropriate measures are taken to provide the necessary care and treatment for the patient's condition.

12. Here at the RHJ VAMC, a missing child alert is announced overhead as

Amber Alert

Ahsley Alert

Code Adam

Missing Child Alert

per CMP 07B-13-10, Missing Child Alert.
The Nationwide missing child alert. Only specially trained Charleston Police Department (CPD) officers can declare an AMBER ALERT.

Explanation

per CMP 07B-13-10, Missing Child Alert.
The Nationwide missing child alert. Only specially trained Charleston Police Department (CPD) officers can declare an AMBER ALERT.

13. According the Patient Clothing, Valuables, Incidentals and Services CPM, patient's belongings only need to be inventoried upon arrival / admission to the hospital.

True

False

per CPM 118-12-35, Patient Clothing, Valuables, Incidentals and Services

Explanation

per CPM 118-12-35, Patient Clothing, Valuables, Incidentals and Services

14. According to the Alcohol Detox Protocol (AKA, CIWA), when can the protocol be discontinued?

Only upon the MD's order

After a score of less than 8 x 3 in a row

After a score of less than 10 x 3 in a row

After the last dose of the tapered Ativan

per Alcohol Detox Protocol

Explanation

per Alcohol Detox Protocol

15. Signs and symptoms of blood transfusion reaction include [CHECK ALL THAT APPLY]

Fever with or without chills

Tachycardia and/or tachypnea and dyspnea

Hives or rash to the patient's trunk and back

Sudden change in BP

Wheezing

Improvement of the hemoglobin and hematocrit values

per CPM 113-13-01, TRANSFUSION OF BLOOD COMPONENTS &
Mosby's nursing procedure Transfusion Reaction

Explanation

per CPM 113-13-01, TRANSFUSION OF BLOOD COMPONENTS &
Mosby's nursing procedure Transfusion Reaction

Submit

16. What are the nurse's actions for a patient experiencing a blood transfusion reaction? [CHECK ALL THAT APPLY]

Stop the transfusion

Notifiy the MD and Blood Bank

Return the blood bag, transfusion set and patient samples to the Blood Bank with the completed Blood Transfusion Record Form

Report the suspected reaction to Quality Management by calling the Patient Safety Hotline

per CPM 113-13-01, TRANSFUSION OF BLOOD COMPONENTS &
Mosby's nursing procedure Transfusion Reaction

Explanation

per CPM 113-13-01, TRANSFUSION OF BLOOD COMPONENTS &
Mosby's nursing procedure Transfusion Reaction

Submit

17. Once a patient has been deteremined to be 'at risk' for suicide, what are the nurses' actions? [CHECK ALL THAT APPLY]

Report any suicidal self-harm behaviors or threats to the Nurse Manager and physician

Allow the patient to use the restroom in privite to maintain patient privacy.

Remove all patient belongs from the room

CPM 116-13-03, SUICIDAL PRECAUTIONS

Explanation

CPM 116-13-03, SUICIDAL PRECAUTIONS

Submit

18. If you suspect that your patient is having a stroke, do ALL of following, EXCEPT

Make patient NPO

Start an IV and draw labs

Place patient on telemetry

Do nothing unitil the Rapid Response Team to arrives and gives orders

per Neurololgy Stroke Protocol

Explanation

per Neurololgy Stroke Protocol

19. Which of the following statements is TRUE?

Glucometer control solution expires 90 days after opening.

All the above

per IC Guideline # 25, HANDLING AND STORAGE OF SINGLE-USE AND MULTIDOSE MEDICATION VIALS AND UNITS

Explanation

per IC Guideline # 25, HANDLING AND STORAGE OF SINGLE-USE AND MULTIDOSE MEDICATION VIALS AND UNITS

20. Asking a patient their last name and last four digits of thier social security number constitutes proper identificaion? TRUE or FALSE

True

False

per CPM 118-14-23, PATIENT IDENTIFICATION

Explanation

per CPM 118-14-23, PATIENT IDENTIFICATION

21. When is necessary to call Life Point? [CHECK ALL THAT APPLY]

For all discharges

Patients who death is imminent

Patients who are deceased

For all admissions

per CPM 00- 14 - 16, ORGAN AND TISSUE DONOR PROGRAM

Explanation

per CPM 00- 14 - 16, ORGAN AND TISSUE DONOR PROGRAM

Submit

22. Accordng to the RHJ VAMC's CMP for PROCEDURES FOR ACTIVE SHOOTER RESPONSE the employees' responsibilities include [CHECK ALL THAT APPLY]

Immediately calling extension 7251, 7268 or 7911 to report the incident

Immediately locking themselves in a secure room or evacuate if able to do so safely.

Remaining in a secure location until the “All Clear” is given by VA or local Police

Following all instruction given by VA Police or local Police

per CPM 07B-12-15, PROCEDURES FOR ACTIVE SHOOTER RESPONSE.

Explanation

per CPM 07B-12-15, PROCEDURES FOR ACTIVE SHOOTER RESPONSE.

Submit

23. Veteran's state portable orders for "Do Not Resuscitate" (DNR) and /or other life sustaining treatment are recognized by this VA. TRUE / FALSE

True

False

per CMP 11-13-26, ADVANCE HEALTH CARE AND MENTAL HEALTH CARE PLANNING AND RESUSCITATION INSTRUCTIONS
Veteran’s state portable orders for “Do Not Resuscitate” (DNR) and /or other life sustaining treatment are recognized by VHA and authorized VHA practitioners. If the veteran has both an advance directive and state portable order which are inconsistent with one another, priority will be given to the most recent statement by the patient of his/her wishes. (Note: See VHA Handbook 1004.04 for more information specific to state portable orders.)

Explanation

per CMP 11-13-26, ADVANCE HEALTH CARE AND MENTAL HEALTH CARE PLANNING AND RESUSCITATION INSTRUCTIONS
Veteran’s state portable orders for “Do Not Resuscitate” (DNR) and /or other life sustaining treatment are recognized by VHA and authorized VHA practitioners. If the veteran has both an advance directive and state portable order which are inconsistent with one another, priority will be given to the most recent statement by the patient of his/her wishes. (Note: See VHA Handbook 1004.04 for more information specific to state portable orders.)

24. You suspect that your patient is having a stroke. Upon immediate notification of the MD, you are asked to call the stroke team. Who do you call?

7911, ask for the stroke team

1-800-I-CARE

Neurology consult residnet

We don't have a stroke team, the MD is responsible for handeling this his / her self

The Emergency Department

per protocol, Neurology Acute Stroke Protocol

Explanation

per protocol, Neurology Acute Stroke Protocol

25. Glucose management of any patient admitted to this hospital who is wearing a Continuous Subcutaneous Insulin Infusion (CSII) commonly known as an Insulin Pump include [CHECK ALL THAT APPLY]

Place an Endocrinology Consult and CDE consult

Maintain the patient/family/significant other responsible for their CSII pump as well as its supplies

Discontinue the pump and send it home with the family

per CPM 118-13-03, Use of Insulin Pumps During Hospitalization

Explanation

per CPM 118-13-03, Use of Insulin Pumps During Hospitalization

Submit

26. According to the CPM, CONSERVATION OF MEDICAL CENTER LINENS, how can we ensure the control of linens within our areas to prevent pilferage, loss and misuse? [CHECK ALL THAT APPLY]

Linen carts should be covered at all times.

Do not wear patient clothing such as pajama tops, gowns or robes.

Do not use linens for anything else but paient care

per CPM, 137-12-03. CONSERVATION OF MEDICAL CENTER LINENS

Explanation

per CPM, 137-12-03. CONSERVATION OF MEDICAL CENTER LINENS

Submit

27. According to the CPM for ADULT/CHILD VICTIMS OF ALLEGED ABUSE, all suspected abuse must be acted upon. Who is the RHJ VAMC's designated reporter?

The MD

The RN

The Social Worker

The Case Manager

per CPM 122-13-02, ADULT/CHILD VICTIMS OF ALLEGED ABUSE
All professionals have a responsibility to act on all suspected abuse. A person, who, acting on good faith, in an emergency situation, reports or participates in an investigation resulting from a report, is immune from civil and criminal liability which may otherwise result by reason of this action.

Social Work Service has been designated as mandatory reporters for the Ralph H. Johnson VA Medical Center.

Explanation

per CPM 122-13-02, ADULT/CHILD VICTIMS OF ALLEGED ABUSE
All professionals have a responsibility to act on all suspected abuse. A person, who, acting on good faith, in an emergency situation, reports or participates in an investigation resulting from a report, is immune from civil and criminal liability which may otherwise result by reason of this action.

Social Work Service has been designated as mandatory reporters for the Ralph H. Johnson VA Medical Center.

28. A written order must be signed before a patient can be considered 'committed & placed on 1:1.

True

False

2. Once it has been determined that the patient will be committed for psychiatric treatment, the patient will be placed in the safest setting possible and under constant 1:1 supervision to prevent harm to self or others. The consulting mental health provider/psychiatrist will write an order for 1:1 Observation in CPRS and contact the appropriate administrative staff in the clinical area who will then take the lead role in coordinating the continuous observation of the patient.

Explanation

2. Once it has been determined that the patient will be committed for psychiatric treatment, the patient will be placed in the safest setting possible and under constant 1:1 supervision to prevent harm to self or others. The consulting mental health provider/psychiatrist will write an order for 1:1 Observation in CPRS and contact the appropriate administrative staff in the clinical area who will then take the lead role in coordinating the continuous observation of the patient.

29. How does one contact the Ethics Consultation Service? [CHECK ALL THAT APPLY]

Non-urgent consultation requests to the Ethics Consultation Service can be made by calling theEthics Consultation Service Hotline: 789-6910.

There is no ethics consultation service - don't call anyone - figure it out by yourself

PER CPM 00 - 14 - 25, INTEGRATED ETHICS, Attachment A

Explanation

PER CPM 00 - 14 - 25, INTEGRATED ETHICS, Attachment A

Submit

30. Where can one find the 'frequency of IV tubing changing'. Yes, on the T drive, but where?

CPM for IV administraion

Service Line Policy under Mosby's Nursing Skills

Clinical Protocols and Guidelines for the prevention of central line blood stream infections

Infection Control Guideline # 16, Prevention of IV Device Related Infection

The correct answer is "Infection Control Guideline # 16, Prevention of IV Device Related Infection." This source specifically focuses on the prevention of infections related to IV devices, which would likely include information on the frequency of IV tubing changing. The other options listed are not as directly related to IV device infections or may not provide specific information on IV tubing changing frequency.

Explanation

The correct answer is "Infection Control Guideline # 16, Prevention of IV Device Related Infection." This source specifically focuses on the prevention of infections related to IV devices, which would likely include information on the frequency of IV tubing changing. The other options listed are not as directly related to IV device infections or may not provide specific information on IV tubing changing frequency.

31. Provider priviledges can be found on the U drive?

True

False

provider priviledges are found on the T drive under PRIVILEDES folder

Explanation

provider priviledges are found on the T drive under PRIVILEDES folder

32. Total Parental Nutrition (TPN) administration guidelines can be found on the T drive under -

CPM

Service Line Policies

Clinical Guidelines and Protocols

Infection Control Guidelines

ICG # 17

Explanation

ICG # 17

33. According to the MISSING PATIENT POLICY, an "at risk patient" [CHECK ALL THAT APPLY]

Is legally committed.

Has a court appointed legal guardian.

Is considered dangerous to self or others.

Lacks cognitive ability (either permanently or temporarily) to make relevant decisions.

Has physical or mental impairments that increase their risk of harm to self or others.

per CPM 07B-13-01, MISSING PATIENT POLICY

Explanation

per CPM 07B-13-01, MISSING PATIENT POLICY

Submit

34. What are the nursing actions for a spinal cord injury patient in autonaumic dysreflxia crisis? [CHECK ALL THAT APPLY]

Sit the patient up and recheck the BP

Loosen / remove all clothes below the waist including socks

Check the patient for any stool impaction

Check the paitne for a full bladder

Be prepared to apply 1" NTG paste if BP remains elevated and causes cannot be easily eliminated

per SCI Treatment and Guideline for Nurses and Physicians

Explanation

per SCI Treatment and Guideline for Nurses and Physicians

Submit

35. This is a latex free facility. TRUE / FALSE

True

False

per CPM 118-12-08, LATEX ALLERGY/SENSITIVITY

Explanation

per CPM 118-12-08, LATEX ALLERGY/SENSITIVITY

36. Please hold the tube feeding for 1hour before and 1hour after administration of medication[CHECK ALL THAT APPLY]

Warfarin

Monoamine Oxidase Inhibitors

Phenytoin

Disulfiram

per CPM 120-14-07, DRUG - NUTRIENT INTERACTION POLICY

Explanation

per CPM 120-14-07, DRUG - NUTRIENT INTERACTION POLICY

Submit

37. What medications can be sent home with a patient at discharge? [CHECK ALL THAT APPLY]

Insulin

Unopened inhalers

Eye drops

Ointments / creams

per CPM 119-14-06, PROVIDING BULK INPATIENT MEDICATIONS ON DISCHARGE FOR OUPATIENT USE

Explanation

per CPM 119-14-06, PROVIDING BULK INPATIENT MEDICATIONS ON DISCHARGE FOR OUPATIENT USE

Submit

38. According to the CPM for ADULT VICTIMS OF ALLEGED ACUTE SEXUAL ASSAULT, this VA treats acute alleged sexual assaults. TRUE / FALSE

True

False

per CPM 11-14-40, ADULT VICTIMS OF ALLEGED ACUTE SEXUAL ASSAULT
Patients will be transferred for medical care and treatment and for forensic examination

Explanation

per CPM 11-14-40, ADULT VICTIMS OF ALLEGED ACUTE SEXUAL ASSAULT
Patients will be transferred for medical care and treatment and for forensic examination

39. How should the nurse respond to VIEW ALERTS? [CHECK ALL THAT APPLY]

Ignore them - that's not my job

Acknowledge them by signing them

Sign them - even if it was sent erronously

What's view alert?

View Alerts are the responsibility of every employee of the Medical Center. All employees with a CPRS/Vista account must ensure alerts are resolved in a timely manner.
C. If View Alerts are erroneously sent to an employee an action is still required. Employees must contact the sender (previous signer) for explanation or forward to appropriate individual within 7 days of receipt.

Explanation

View Alerts are the responsibility of every employee of the Medical Center. All employees with a CPRS/Vista account must ensure alerts are resolved in a timely manner.
C. If View Alerts are erroneously sent to an employee an action is still required. Employees must contact the sender (previous signer) for explanation or forward to appropriate individual within 7 days of receipt.

Submit

40. Match the item with the proper cleaning method - according to our RME policy and procedure

Stainless Steel Instrument tray being returned to SPS

Site Rite / ultrasound machine

Alaris Pump Modules

Submit

Fy 15: ICU Annual Policy / Procedure Review