DHA Nursing Patient Assessment and Clinical Skills 2 — Questions and Answers
Question 1: What is the DHA protocol for blood glucose monitoring in hospitalized patients?
- Only test fasting glucose on admission
- Monitor before meals and at bedtime for diabetic patients, with additional checks for insulin drips or symptomatic patients (Correct answer)
- Test only when symptoms appear
- Once weekly for all patients
Correct answer: Monitor before meals and at bedtime for diabetic patients, with additional checks for insulin drips or symptomatic patients
DHA protocols require blood glucose monitoring before meals and at bedtime for diabetic patients, with more frequent monitoring (every 1-2 hours) for patients on insulin infusions or experiencing glycemic instability.
Question 2: How should a DHA nurse perform a pain assessment for a non-verbal patient?
- Assume no pain if the patient is not crying
- Use behavioral pain assessment tools such as the FLACC scale or CPOT, observing facial expressions, body movements, and vital signs (Correct answer)
- Only assess pain when family members are present
- Ask the physician to assess pain
Correct answer: Use behavioral pain assessment tools such as the FLACC scale or CPOT, observing facial expressions, body movements, and vital signs
For non-verbal patients, DHA nurses use validated behavioral pain assessment tools (FLACC, CPOT, BPS) that evaluate facial expressions, body movements, muscle tension, and physiological indicators.
Question 3: What is the DHA standard for patient identification before medication administration?
- Asking the patient their name only
- Using at least two patient identifiers such as full name and medical record number, verified against the medication order and ID band (Correct answer)
- Checking the room number only
- Verifying with the patient's family member
Correct answer: Using at least two patient identifiers such as full name and medical record number, verified against the medication order and ID band
DHA patient safety standards require verification of at least two identifiers (typically full name and medical record number/date of birth) against the medication order and patient ID band before any medication administration.
Question 4: What is the DHA nursing protocol for assessing a patient's fall risk?
- Only assess patients over 65 years old
- Use a validated fall risk assessment tool on admission, after a fall, with any change in condition, and at regular intervals (Correct answer)
- Only assess surgical patients
- Fall risk assessment is optional
Correct answer: Use a validated fall risk assessment tool on admission, after a fall, with any change in condition, and at regular intervals
DHA requires fall risk assessment using validated tools (such as the Morse Fall Scale) on admission, after any fall event, whenever the patient's condition changes, and at regular intervals throughout hospitalization.
Question 5: How should a DHA nurse assess and document fluid balance?
- Estimate fluid intake visually
- Accurately measure and record all fluid intake and output including oral, IV, urine, drainage, and insensible losses (Correct answer)
- Only measure urine output
- Documentation is only needed for ICU patients
Correct answer: Accurately measure and record all fluid intake and output including oral, IV, urine, drainage, and insensible losses
DHA standards require accurate measurement and documentation of all fluid intake (oral, IV, enteral) and output (urine, drainage, vomiting, wound output) to maintain an accurate fluid balance record.
Question 6: What is the DHA protocol for monitoring patients receiving blood transfusions?
- Check vital signs only before starting
- Monitor vital signs at baseline, 15 minutes, 30 minutes, hourly during transfusion, and post-transfusion, watching for transfusion reactions (Correct answer)
- Only monitor the drip rate
- No monitoring is required for blood transfusions
Correct answer: Monitor vital signs at baseline, 15 minutes, 30 minutes, hourly during transfusion, and post-transfusion, watching for transfusion reactions
DHA blood transfusion monitoring requires vital signs at baseline, 15 minutes after starting, then at 30-minute to hourly intervals during the transfusion, and after completion, with continuous observation for reactions.
DHA Nursing Patient Assessment and Clinical Skills 2
What is the DHA protocol for blood glucose monitoring in hospitalized patients?