PROCEL TEMPORARY SERVICES, INC.

Procel Temporary Services Inc.


JOB DESCRIPTION: REGISTERED NURSE

EFFECTIVE DATE: SUPERSEDES:
Š August 1, 2006 Š May 10, 2005

APPROVED BY: Marylin Stephens, RN, MSN, MBA, Chief Executive Officer

_______________________________________ ___________________________
**EMPLOYEE SIGNATURE DATE

RESPONSIBLE TO:
Š The Registered Nurse is responsible to the Charge Nurse of their specific unit.

QUALIFICATION:
Educational –
Š High School Graduate
Š Current California State License
Š Current BCLS (Additional credentials may be required by specialty)
Experience –
Š One-Year Experience Required - Two- Year Experience For Specialty Units

RESPONSIBILITIES:
Š Diagnosis and treatment of human responses to actual or potential health problems based on
interpretation of assessment data
Š Formulation of a care plan or treatment regimen in collaboration with other disciplines and the
patient to assure safety, comfort, hygiene, protection, prevention and restoration of health
Š Planning and providing nursing care, explanation of treatments to the patients and education of
the patient and family regarding how to care for the patient’s health care needs
Š Evaluating the effectiveness of treatment based on patient’s response/outcome and modification
of the plan as needed in collaboration with the patient and the health team
Š Acting as a patient advocate by initiating actions in accordance with the patient’s wishes and by
providing the patient with sufficient information to make informed decisions
Š Planning, delegating and supervising tasks performed by non-licensed staff within the limits of
the law and staff’s job responsibilities
Š Administration of medications and therapeutic agents as ordered by a duly licensed practitioner
authorized to do so under the provision of section 1316.5 of the Health and Safety Code
Š Performance of skin tests, immunization techniques and withdrawal of blood from peripheral
veins or specific venous access devices
Š Following approved standardized procedures of each Facility
Š Documentation of initial assessments, reassessments, interventions and patient’s response to
interventions

© PROCEL

PROCEL TEMPORARY SERVICES, INC.
Š Documentation of the ability of patient’s and/or family to manage continuing care needs after
discharge
Š Evaluation of care by utilizing continuous performance improvement monitoring activities and
patient outcomes
Š Utilization of standards of patient care and standards of practice to provide patient care.
Š Utilizations of resources such as the Code for Nurses, the patient Bill of Rights and other
hospital established structures to guide ethical decision making.
Š Provide care to patients and their significant others taking into consideration their cultural,
religious, and social preferences as well as age specific care needs and incorporating these
needs in the development and implementation of their plan of care.

SPECIALTIES:
Certain units require special training, skills and proven competency in addition to the usual skills
of the Registered Nurse. These areas include, but are not limited to, the following:

Intensive Care, Coronary Care Neonatal Intensive Care Unit (NICU)
Telemetry/DOU Rehabilitation
Emergency Department Post Partum
Operating Room Psychology
PACU/Recovery Room Medical Surgical
Mental Health Pediatric Intensive Care Unit (PICU)
Obstetrics Pediatrics
































© PROCEL
Disclosur e and Author i zati on to Obtai n I nvestigative Consumer Repor t

In connection with my application for employment or promotion or other job change, I understand that
Procel Temporary Services, Inc. (the Company) may obtain an INVESTIGATIVE CONSUMER
REPORT that will include information as to my character, general reputation, personal characteristics and mode of
living. This report may reveal information about work habits, including oral assessments of my job performance,
experiences and abilities, along with reasons for termination of past employment. Such a report may be requested by
the Company or on behalf of the Company. Further, I understand and agree that the Company may request
information from various federal, state, and other agencies, including public and private sources which maintain
records concerning my past activities relating to my driving record, credit history, criminal record, civil matters,
previous employment, educational background and professional licensing, if any.

Report may be ordered from:

Interstate Data/Megacriminal.com 113 Latigo Lane #401 Canyon City, CO 81212 (800)332-7999
Consumer Reporting Agency Name Address City, State, Zip Telephone

and/or

KROLL Background Check 600 Third Ave New York, NY 10016 (888)209-9526
Consumer Reporting Agency Name Address City, State, Zip Telephone

and/or

Insight Investigations, Inc. PO Box 891571 Temecula, CA 92589 (800)615-8111
Consumer Reporting Agency Name Address City, State, Zip Telephone

You have the right, upon written request made within a reasonable period of time (not to exceed 30 days) after
receipt of this notice to receive a written disclosure of the nature and scope of any investigation.

If a consumer investigative report is obtained and an adverse decision is made affecting your employment, the
Company will provide to you, before making the adverse decision, a copy of the investigative consumer report and a
description in writing of your rights under the Fair Credit Reporting Act.


You have a right to obtain a copy of any investigative consumer report obtained by Procel Temporary Services, Inc.
by checking the box provided. The report will be provided to you within three business days after the report is
provided to Procel Temporary Services, Inc.
I request to receive a free copy of this report by checking this box. x
Under section 1786.22 of the California Civil Code, you may view the file maintained on your by the consumer
reporting agency named above during normal business hours. You may also obtain a copy of this file upon
submitting proper identification and paying the costs of duplication services, by appearing at the Consumer
Reporting Agency identified above in person or by mail. You may also receive a summary of the file by telephone.
The agency is required to have personnel available to explain your file to you and the agency must explain to you
any coded information appearing in your file. If you appear in person, a person of your choice may accompany you,
provided that this person furnishes proper identification.


Disclosur e and Author i zati on to Obtai n I nvestigative Consumer Repor t

I acknowledge that a fax or copy of this Disclosure and Authorization bearing my signature shall be valid as the
original. This release is valid for all federal, state, county and local agencies and authorities. I acknowledge that I
have received a copy of the Summary of Rights pursuant to the Fair Credit Reporting Act (FRCA).


Name


Address


City State Zip

( ) -
Home Telephone Social Security Number


Date of Birth Driver s License #


State of Issue







Applicant Signature
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Date: _
Skills Checklist
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Nationally Validated Content
Copyright © 2010 Clearview Staffing Software Inc.
Page 1 of 6

Emergency Room
Using the scale(s) below, please complete the following skill self assessment based upon your experience within the last 2 years.
Proficiency: [1] None [2] Intermittent [3] Experienced [4] Supervise/Teach
Frequency: [1] Never/Observed Only [2] Less than 6 times/year [3] Twice a Month [4] Daily - Weekly
Assessment/Patient Care
Proficiency Frequency
1 2 3 4 1 2 3 4
General
Admission
Advance Directives
Collect Appropriate
Data
Discharge Teaching
Organ/Tissue
Donation
Patient and Family
Teaching
Suspected Abuse
EMTALA Procedures
Computerized Documentation
Computerized
Documentation
Cardiovascular
General
Abnormal Heart
Sounds/Murmurs
Auscultation (Rate,
Rhythm)
Patient Experience
Abdominal Aortic
Aneurysm
Acute Angina
Acute C.H.F.
Acute MI
Cardiac Arrest/CPR
Cardiac Tamponade
Cardiomyopathy
Defibrillation/Cardioversion
Hypertension
Myocardial Contusion
Pacemaker --
External
Pacemaker --
Permanent
Monitoring

Assessment/Patient Care Continued
Proficiency Frequency
1 2 3 4 1 2 3 4
12 Lead EKG
Interpretation
Arrhythmia Interpretation
Arterial Line
CVP Monitoring
Intra-Aortic Balloon
Pump
PA/Swan-Ganz
Labs
BNP (Brain Natriuretic
Peptide)
Cardiac Enzymes &
Isoenzymes
Coagulation Studies
Troponin
Pulmonary
General
Assess Lung Sounds
Identify/Manage Resp.
Complications
Oxygenation Status
Rate and Work of
Breathing
Patient Experience
Acute Pneumonia
ARDS
Aspiration
Chest Trauma
Chest Tube
COPD
Hemopneumothorax
Inhalation Injuries
Near Drowning
Pulmonary Edema
Pulmonary Emboli
Status Asthmaticus
Tension Pneumothorax
Tracheostomy
Tuberculosis
Monitoring
Apnea

Name: _
Date: _
Skills Checklist
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Nationally Validated Content
Copyright © 2010 Clearview Staffing Software Inc.
Page 2 of 6

Emergency Room
Using the scale(s) below, please complete the following skill self assessment based upon your experience within the last 2 years.
Proficiency: [1] None [2] Intermittent [3] Experienced [4] Supervise/Teach
Frequency: [1] Never/Observed Only [2] Less than 6 times/year [3] Twice a Month [4] Daily - Weekly
Assessment/Patient Care Continued
Proficiency Frequency
1 2 3 4 1 2 3 4
Pulse Oximetry
Lab
Interpretation of
ABGs
Neurology
General
Glasgow Coma Scale
Neurological
Assessment
Reflex/Motor
Deficits
Visual Communication
Deficits
Patient Experience
Acute Head Injury
Alzheimer's Disease
Basal Skull Fracture
Cerebral Hemorrhage/Aneurysm
Closed Head Injury
CNS Infection
Coma
CVA
DTs
Increased ICP
Intracranial
Hemorrhage
Meningitis
Neuromuscular
Disease
Seizure Disorder
Spinal Cord Injury
Halo Traction/Cervical
Tongs
Neurogenic Shock
TIAs
Monitoring
ICP Monitoring
Gastrointestinal
General

Assessment/Patient Care Continued
Proficiency Frequency
1 2 3 4 1 2 3 4
Assess Nutritional
Status
G.I. Assessment
Patient Experience
Abdominal Trauma
Abdominal Wounds
and Surgeries
Acute GI Bleed
Bowel Obstruction
Esophageal Bleed
Hepatitis
Ileostomy
Liver Failure
Pancreatitis
Paralytic Ileus
Poison Ingestion
Labs
LFTs (Liver Function
Test)
Serum Ammonia
Serum Amylase
Renal/Genitourinary
General
Assess Fluid Status
Patient Experience
Acute Renal Failure
End Stage Renal
Disease
Peritoneal Dialysis
Renal Rejection
Syndrome
Renal Transplant
Suprapubic Cath
Urinary Tract
Infection
Fistula/Shunt
Monitoring
Fluid Balance
Measurement of I & O
Labs
BUN & Creatinine

Name: _
Date: _ Skills Checklist
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Nationally Validated Content
Copyright © 2010 Clearview Staffing Software Inc.
Page 3 of 6

Emergency Room
Using the scale(s) below, please complete the following skill self assessment based upon your experience within the last 2 years.
Proficiency: [1] None [2] Intermittent [3] Experienced [4] Supervise/Teach
Frequency: [1] Never/Observed Only [2] Less than 6 times/year [3] Twice a Month [4] Daily - Weekly
Assessment/Patient Care Continued
Proficiency Frequency
1 2 3 4 1 2 3 4
Serum Electrolytes
Endocrine/Metabolic
Patient Experience
Adrenal Gland
Disorders
Diabetic Ketoacidosis
Drug Overdose
Insulin Shock
Pituitary Gland
Disorders
Diabetic Coma
Insulin Reaction
Thyroid Gland
Disorders
Labs
Blood Glucose
Thyroid Studies
Musculoskeletal
General
Pulse/Circulation
Checks
Patient Experience
Amputation
External Fixation
Multiple Trauma
Paraplegia
Skeletal/Skin
Traction
Cast Care
Fractures
Crutch Walking
Immunology/Hematology/Oncology
General
Blood Transfusions
Patient Experience
Acute Leukemia
Anaphylactic Shock
Cancer
HIV/AIDS

Assessment/Patient Care Continued
Proficiency Frequency
1 2 3 4 1 2 3 4
Sepsis
Sickle Cell Anemia
Treatment Side Effects
Chemo/Radiation
Labs
Hematology
Wounds/Integument
General
S/S Infection
Skin Assessment
Patient Experience
Burns
Hazardous Material
Exposure
Pressure Sores
Shingles
Staged Decubitus
Ulcers
Stasis Ulcers
Surgical Wounds
Surgical Wounds
w/Drains
Traumatic Wounds
Monitoring
Skin Breakdown
Women's Health
General
Abruptio Placenta
DIC
Eclampsia
Hemorrhage
Precipitous Delivery
Preeclampsia
Premature Labor
Rape Kit
Spontaneous Abortion
Medications/Therapeutic Interventions
General
Adenocard

Name:, _
Date: _
Skills Checklist
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Nationally Validated Content
Copyright © 2010 Clearview Staffing Software Inc.
Page 4 of 6

Emergency Room
Using the scale(s) below, please complete the following skill self assessment based upon your experience within the last 2 years.
Proficiency: [1] None [2] Intermittent [3] Experienced [4] Supervise/Teach
Frequency: [1] Never/Observed Only [2] Less than 6 times/year [3] Twice a Month [4] Daily - Weekly
Medications/Therapeutic Interventions Continued
Proficiency Frequency
1 2 3 4 1 2 3 4
Adrenalin
Antiemetics
Antispasmodic
Atropine
Bicarbonate
Bretylium (Bretylol)
Bumex
Cardizem (Diltazem)
Charcoal
Decadron
Dilantin
Dobutamine
Dopamine
Epinephrine
Esmolol
Heparin
Insulin
Ipecac
Isuprel
Lanoxin
Lasix
Lidocaine
Mannitol
Nipride (Nitroprusside)
Nitroglycerin
Nitroprusside
Paralytics
Phenobarbital
Pitressin
Pronestyl (Procainamide)
Retavase
Solu-Medrol
Steroids
Streptokinase
Tenectaplase
(TNKase)
Terbutaline
TPA/Thrombolytics
Verapamil
Versed
Theophylline

Medications/Therapeutic Interventions Continued
Proficiency Frequency
1 2 3 4 1 2 3 4
Medications Administration
Administer IM and
SQ Meds
Administer Inhalation
Medications
Administer PO
Medications
Bladder Irrigation and
Instillation
Ear Irrigation
Eye Irrigation
Needleless Systems
IV Therapy
Adverse Reactions
Assess/Maintain IV
Site
CVP Lines/Measurement
of CVP
Infusion Pumps
Peripheral IV
Insertion
Syringe Pumps
Vascular Access Devices
Care/Maintenance
Administer IV
Medications
Mixing IV Solutions
Blood
Administer Blood/Blood
Products
Albumin
Nutritional Therapy
NGT Insertion
TPN and Hyperalimentation
Oxygen Administration
Ambu-Bag
Nasal Cannula

Name: _
Date: _
Skills Checklist
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Nationally Validated Content
Copyright © 2010 Clearview Staffing Software Inc.
Page 5 of 6

Emergency Room
Using the scale(s) below, please complete the following skill self assessment based upon your experience within the last 2 years.
Proficiency: [1] None [2] Intermittent [3] Experienced [4] Supervise/Teach
Frequency: [1] Never/Observed Only [2] Less than 6 times/year [3] Twice a Month [4] Daily - Weekly
Medications/Therapeutic Interventions Continued
Proficiency Frequency
1 2 3 4 1 2 3 4
Nebulizer Treatments
Non-Rebreather Mask
Portable Oxygen
Tracheostomy
Venti Mask
Ventilator (A/C, IMV,
PEEP)
Pain Management
Assess Pain
Level/Tolerance
Moderate Sedation
Ramsey Scale
Procedures/Equipment
Perform
Applying Brace/Splint
Cast
Cervical Collar
Chest Tube Drainage
Systems
Crisis Intervention
Doppler
Drains (JP-Hemovac-Penrose)
Dressing Changes
Establish/Protect
Airway
Foley, 3-Way
Foley, Female
Foley, Male
Hyper/Hypothermia
Blanket
Iced Saline Lavage
Isolation
Pinned Fractures
Restraints
Steristrips
Suctioning (Oral-Naso-Pharynx)
Suicide Precautions
Trach Care/Suctioning
Wound Care/Irrigations
Wrist Splint

Procedures/Equipment Continued
Proficiency Frequency
1 2 3 4 1 2 3 4
Specimen Collections
Arterial Line Draw
Assist with Rape Exam

Butterfly Stick
Central Line Draw
Clean Catch Urine
Cultures-Blood
Dipstick Urine
Finger Stick
Stool
Sputum
Sterile Urine
Throat Swabs
Venipuncture
Assist
Arterial Line
Insertion
Bedside Invasive
Procedures
Bronchoscopy
Cardioversion/Defibrillation
Central Line
Insertion
Chest Tube Insertion
Emergency Tracheostomy
ET Intubation and
Extubation
Halo Traction/Cervical
Tongs Placement
IV Cutdown
Lumbar Puncture
Nasal Packing
Open Chest Emergency
PA Catheter/Swan-Ganz
Insertion
Pericardiocentesis
Pericentesis
Staples Assist/Removal
Sutures Assist/Removal

Name: _
Date: _
Skills Checklist
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Nationally Validated Content
Copyright © 2010 Clearview Staffing Software Inc.
Page 6 of 6

Emergency Room
Using the scale(s) below, please complete the following skill self assessment based upon your experience within the last 2 years.
Proficiency: [1] None [2] Intermittent [3] Experienced [4] Supervise/Teach
Frequency: [1] Never/Observed Only [2] Less than 6 times/year [3] Twice a Month [4] Daily - Weekly
Procedures/Equipment Continued
Proficiency Frequency
1 2 3 4 1 2 3 4
Thoracentesis
Insert Temp-Pacemaker
Age Group Experience
Age Groups
0 - 30 Days
30 Days - 1 Year
1 - 3 Years
3 - 5 Years
5 - 12 Years
12 - 18 Years
18 - 39 Years
39 - 64 Years
64+ Years
Trauma Level Experience
Level I
Level II
Level III
Clinical Settings
Acute Care ER
Chest Pain ER
CHF Clinic
Flight Nursing
Pacemaker Clinic
Urgent Care Clinic
Ambulance/Transport

Signature
Date
"Gold Seal of Approval"




Application Form
TO APPLI CANTS: We deeply appreciate your interest in our organization and assure you that we are sincerely interested in your
qualifications. A clear understanding of your background and work history will aid us in placing you in a position that is best suited
for you.


1. PERSONAL:

Name: _________________________________________________________________________________________
(Last) (First) (Middle)

Address: (Current) _______________________________________________________________________________
(Number) (Street) (Apt/Unit/Suite #)

________________________________________________________________________________________
(City) (State) (Zip/Postal Code)

Permanent Address: _________________________________________________________________________________
(If different from above) (Number/Street/Apt) (City/State) (Zip)

Telephone Number (s): Home/Day: (____) _______-____________ Cell/Pager: (____) _______-____________

I n Case of Emer gency, Contact: Name: _____________________ Number: (____) _______-____________

E-Mail Addr ess: ____________________________________________________________________________

I NTERESTED I N: x PER DI EM x TRAVEL


2. Licensure/Credentials:

State: License Number: Expiration Date:
State License: _____________________ # _____________________ (Mo) _________ (Yr) __________
_____________________ # _____________________ (Mo) _________ (Yr) __________
Foreign: _____________________ # _____________________ Date Obtained: ________________

Education Pr epar ation:

Name/Address: Year Graduated: Degree(s) Obtained:
High School: ______________________ (Mo)_______(Yr)________ _____________________________
______________________ _______________________ _____________________________
College: ______________________ (Mo)_______(Yr)________ _____________________________
______________________ _______________________ _____________________________


3. Continuing Education for the last two (2) year s:

Completion Date Provider Number Course Name Contact Hours
_____________________ _________________________ _________________________________ __________
_____________________ _________________________ _________________________________ __________
_____________________ _________________________ _________________________________ __________
_____________________ _________________________ _________________________________ __________
_____________________ _________________________ _________________________________ __________
_____________________ _________________________ _________________________________ __________
_____________________ _________________________ _________________________________ __________
_____________________ _________________________ _________________________________ __________



4. Work Experience: (Please provide last seven (7) years wor k history. Most recent or cur rent employer
fi rst)

1) Name and Addr ess of Employer : Employment Dates - Fr om: _____(mo) _______ (yr ) To: _____(mo) _______ (yr )

Employer: Main Phone #:

City, State:

Was this a Tr avel Assignment? x No x Yes Facility Name:

Job Title: Indicate Specific Unit(s):

If you have experience in more than one unit, please indicate how many months/years you have worked in each unit at
this facility:

Unit: __________ Years of Experience: ___________ Unit: __________ Years of Experience: ___________
Unit: __________ Years of Experience: ___________ Unit: __________ Years of Experience: ___________

Duties and Responsibilities:
__________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________


2) Name and Addr ess of Employer : Employment Dates - Fr om: _____(mo) _______ (yr ) To: _____(mo) _______ (yr )

Employer: Main Phone #:

City, State:

Was this a Tr avel Assignment? x No x Yes Facility Name:

Job Title: Indicate Specific Unit(s):

If you have experience in more than one unit, please indicate how many months/years you have worked in each unit at
this facility:

Unit: __________ Years of Experience: ___________ Unit: __________ Years of Experience: ___________
Unit: __________ Years of Experience: ___________ Unit: __________ Years of Experience: ___________

Duties and Responsibilities:
__________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________


3) Name and Addr ess of Employer : Employment Dates - Fr om: _____(mo) _______ (yr ) To: _____(mo) _______ (yr )

Employer: Main Phone #:

City, State:

Was this a Tr avel Assignment? x No x Yes Facility Name:

Job Title: Indicate Specific Unit(s):

If you have experience in more than one unit, please indicate how many months/years you have worked in each unit at
this facility:

Unit: __________ Years of Experience: ___________ Unit: __________ Years of Experience: ___________
Unit: __________ Years of Experience: ___________ Unit: __________ Years of Experience: ___________

Duties and Responsibilities:
__________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________




4. Work Experience: (continued)

4) Name and Addr ess of Employer : Employment Dates - Fr om: _____(mo) _______ (yr ) To: _____(mo) _______ (yr )

Employer: Main Phone #:

City, State:

Was this a Tr avel Assignment? x No x Yes Facility Name:

Job Title: Indicate Specific Unit(s):

If you have experience in more than one unit, please indicate how many months/years you have worked in each unit at
this facility:

Unit: __________ Years of Experience: ___________ Unit: __________ Years of Experience: ___________
Unit: __________ Years of Experience: ___________ Unit: __________ Years of Experience: ___________

Duties and Responsibilities:
__________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________



5) Name and Addr ess of Employer : Employment Dates - Fr om: _____(mo) _______ (yr ) To: _____(mo) _______ (yr )

Employer: Main Phone #:

City, State:

Was this a Tr avel Assignment? x No x Yes Facility Name:

Job Title: Indicate Specific Unit(s):

If you have experience in more than one unit, please indicate how many months/years you have worked in each unit at
this facility:

Unit: __________ Years of Experience: ___________ Unit: __________ Years of Experience: ___________
Unit: __________ Years of Experience: ___________ Unit: __________ Years of Experience: ___________

Duties and Responsibilities:
__________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________


6) Name and Addr ess of Employer : Employment Dates - Fr om: _____(mo) _______ (yr ) To: _____(mo) _______ (yr )

Employer: Main Phone #:

City, State:

Was this a Tr avel Assignment? x No x Yes Facility Name:

Job Title: Indicate Specific Unit(s):

If you have experience in more than one unit, please indicate how many months/years you have worked in each unit at
this facility:

Unit: __________ Years of Experience: ___________ Unit: __________ Years of Experience: ___________
Unit: __________ Years of Experience: ___________ Unit: __________ Years of Experience: ___________

Duties and Responsibilities:
__________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________




5. Work References:

Manager/Charge Nurse Name Facility Position Contact Number
1. _________________________________ ___________________ ___________________ ______________________
2. _________________________________ ___________________ ___________________ ______________________
3. _________________________________ ___________________ ___________________ ______________________
4. _________________________________ ___________________ ___________________ ______________________



6. I have a MI NI MUM OF ONE-YEAR experience in the following units and I am prepared to car e for
patients in these specialties:

x General Medical/Surgical x PICU
x Hospice Care x NICU
x Telemetry x Labor & Delivery
x Stepdown x PEDS C/V
x Intensive Care/ICU x PEDS General
x PACU x PEDS Oncology
x Operating Room x Nursery II
x Emergency Room x Nursery N/B
x Outpatient Clinic x Couplet Care
x Cath Lab/Cardiology x Surgery Center
x Pre-Op Holding x Psychiatric General
x Post-Op Care x Chemical Dependency
x GI-LAB x Adolescent Psychiatric


7. Refer ral Source: x Walk In x Nurseweek x Nurse Magazines x Healthcare Traveler Journal
x Monster.com x Internet/Web x Career Builder x Hospital Referral
x Nurse Referral Name: First ______________ Last ______________
Phone Number: _____________________ and/or Email: __________________________
x Other: __________________________________________________________


8. Have you ever been convicted of any crime? x YES x NO

If so, WHEN? Date: _____________________ Place: __________________________________________________

An Affirmative Response is not an automatic bar from employment.

(Remi nder to appl i cants: We do Cr i mi nal Backgr ound Scr eeni ng on ALL appl i cants befor e hi r e)


Do you drive? x YES x NO

Do you have a car or other transportation for wor k? x YES x NO

What languages other than English do you speak/write and understand?

_________________________________________________________________________________________






Employment Agr eement

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for
employment and that the answers given by me are true and correct to the best of my knowledge. I hereby certify that I,
the undersigned applicant, have personally completed this application. I understand that any omission or misstatement
of material fact on this application or any documentation used to secure employment shall be ground for rejection of
this application, or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

I hereby authorize Procel Temporary Services, Inc. (Procel) to thoroughly investigate my references, work record,
education, and other matters related to my suitability for employment. I further authorize my former employers to
disclose Procel all letters, reports and other information related to my work records, without giving me prior notice of
such disclosure. In addition, I hereby release Procel my former employers, and all other persons, corporations,
partnerships and associations from any and all claims, demands, or liabilities arising, or that may arise, our of, or in
any way related to, such investigation or disclosure.

I understand that nothing contained in the application or conveyed during any interview that may be granted is
intended to create an employment contact between Procel and myself. In addition, I understand and agree that if I am
employed, my employment is At Will and is for no definite or determinable period and may be terminated at any time,
with or without prior notice, and for any reason or no reason, at the option of either myself or Procel and that promises
or representations contrary to the forgoing or given at any time in the future are not binding.

I understand it is the Policy of Procel to comply with the Drug-Free Workplace Act of 1988, and to refer all qualified
candidates, without regard to race, color, national origin, sex, age, physical handicap or medical condition in
accordance with the Federal and State Equal Opportunity Laws. I further understand that Procel complies with all
applicable Accreditation of Healthcare Organizations (Joint Commission) and with regulations related to HIPAA
Security Compliance.



Applicant Name (PLEASE PRINT) Date



Applicant Signature




















Revised: 03/11/11




DRUG AND ALCOHOL POLICY

I. STATEMENT OF PURPOSE OF POLICY
PROCEL TEMPORARY SERVICES, INC. recognizes the legal and moral responsibility to provide a safe and
productive work environment for all employees. Statistics show that drug and alcohol use in the workplace results in
accidents, injuries, lower productivity, lost profits, increased health care costs, and legal difficulties for employees and
employers. Clearly the use, possession or sale of illegal drugs and alcohol in the workplace poses serious risks to the
health, safety and well being of our employees. For these reasons, we have adopted this policy that all employees must
repot to work completely free fro the presence of illegal drugs and the effects of alcohol.

II. ILLEGAL DRUG USE AND DISTRIBUTION
All employees are prohibited from manufacturing, cultivating, distributing, dispensing, possessing or using illegal or
other mind-altering or intoxicating substances while on Company premises (including parking areas and other
Company grounds), or while otherwise performing duties away, from the Company premises. Employees shall not
report to work with illegal substances in their systems.

III. ALCOHOL AND USE IMPAIRMENT
All employees are prohibited from using alcohol on Company property on while on Company related business, without
the prior approval of the CEO. Furthermore, all employees are prohibited fro having alcohol in their systems while at
work or on duty. In the selected circumstances when alcohol use has been permitted, alcohol abuse, unruly or un-
business like behavior will not be tolerated and may result in discipline, up to and including termination.

IV. PRESCRIPTION DRUGS
The use of prescription drugs, as part of a prescribed medical treatment by a licensed physician is not prohibited. An
employee is required to inform his or her supervisor if the legal use of a prescription drug will in any way affect the
ability to safely perform his or her assigned job. It is in the employee’s responsibility to determine whether a prescribed
drug may impair job performance.

V. DRUG TESTING
Employee’s who test positive, admit to drug and alcohol use or distribution, and who are not terminated, will not be
returned to work until they have been evaluated by the Company’s coordinating physician (MRO) in conjunction with
the management to determine if they can safely return to work. Results and record of drug tests are confidential and
handled on a need-to-know basis. Laboratory reports test results shall appear in an employee’s personnel folder in a
secured location (envelope). The release of drug test results is strictly forbidden without the specific consent of the
applicant or employee authorizing release of his or her information. Prior to administering any drug test, a written
release of the results of that test will be obtained from the employee or applicant being testes.

APPLICANTS FOR EMPLOYMENT
All applicants will be informed that as a part of an offer of employment, the applicant will be required to
undergo a drug test. Applicants who decline to undergo the drug test will not be considered for employment.
Applicants who test positive will be reviewed by the Medical Review Officer and depending on that report a
decision to hire will be made.

REHABILITATION MONITORING
An employee who tests positive in a confirmed drug test, or who has successfully completed a drug or
alcohol drug rehabilitation program as a condition of continued employment to sign an agreement which will
include periodic random testing for a specific period of time following his or her reentry.


VI. POSITIVE TEST RESULTS
Any employee, who tests positive in a confirmed drug test, will be reviewed by the MRO and depending upon that
report will be subject to discipline up to and including termination. Employees who are not immediately terminated for
testing positive or for some other violation of the policy may at the sole discrete of the Company, be suspended without
pay pending a review of an MRO (medical review officer) or other responsible corporate officer.






VII. NOTIFICATION OF IMPAIRMENT
It shall be the responsibility of each employee who observe or has knowledge of another employee in a condition which
impairs the employee’s ability to perform their job duties, or who presents a hazard to the safety of others, or is
otherwise in violation of this policy, to promptly report that fact to their immediate supervisor.

VIII. EMPLOYEE ASSISTANCE
The Company expects employees who suspect they have an alcohol or drug problem to seek treatment. The
Company will help employees who abuse alcohol or drugs by providing a referral to an appropriate professional
organization. However, it is the responsibility of the employee to seek and accept assistance before drug and alcohol
problems lead to disciplinary action, including termination. Failure to enter, remain or successfully complete a
prescribed treatment program may result in termination of employment. Strict confidentiality of records and
information will be maintained.

Nothing in this section shall be constructed to prohibit the Company from imposing discipline for violations of other
work rules or misconduct committed by an employee who voluntarily enters an Employee Assistance Program.

IX. SEARCHES, INSPECTIONS AND TESTING
Where the Company has reasonable suspicion that an employee has violated the drug and alcohol policy, management
retains the right to inspect all personal and company property, which is or may be a part of the policy violation. The
right to inspect will include but not limited to vehicles (both personal – while on company property – and company
owned), desks, purses and briefcases. Employees will be expected to cooperate in the conduct of such inspections as a
condition of continued employment. Where the employee is not present or refuses to remove a personal lock, the
Company may do so for him or her and compensate the employee for the lock. Many facilities require a drug screen 30
days prior to starting a travel assignment. Should a facility have reason to believe that a Nurse/Tech has a substance
abuse problem, the Nurse/Tech will be asked to take a drug screen. Refusal will result in termination.

X. DISCIPLINARY ACTIONS
Violations of this policy will result in disciplinary action. Disciplinary action may include suspension and/or immediate
termination of employment. Employment may be terminated even for a first time violation.

XI. INVOLVEMENT OF LAW ENFORCEMENT AGENCIES
The use, sale, purchase, transfer or possession of an illegal drug is usually a violation of law. The Company may refer
such illegal drug activities to law enforcement agencies.

XII. ACKNOWLEDGEMENT OF UNDERSTANDING
I acknowledge receipt of the Company’s Drug and Alcohol Abuse Policy. I understand that it is my responsibility to
read and comprehend its on contents and should I have any questions, I will contact my supervisor.

Nothing in this policy alters my status as an “at will” employee. I have the right to terminate my employment with or
without cause at any time and I understand that the Company has a similar right.



__________________________________________________________________
First Name Last Name


___________________________________________________________________
Employee Signature Date



This policy should not be considered as a contractual in nature. It represents PROCEL’s current standards for dealing
with a serious national problem and is subject to change.




REFERENCE CHECK FORM
APPLI CANT I NFORMATI ON


Speci al t y : Cl assi f i cat i on:


Name:


Em pl oy ed:

From:

To:
REFERENCE I NFORMATI ON

Name:

Ti t l e:

Ph one:


Uni t :

Faci l i t y :

Ad dr ess:

Ci t y :

St at e:

Zi p:
EVALUATI ON
Per sonal Eval uat i on Excel l ent Good Fai r Poor
At t endance
Punct ualit y
Qualit y of Work
Perf ormance
Skill
At t it ude
I nit iat ive
Adapt abilit y
Appearance
Co-Operat ion
Wou l d y ou r eh i r e t hi s emp l oy ee? ________ Yes _________ No
Com men t s:
JCAHO CERTIFIED
2447 Pacific Coast Highway Suite #207 Hermosa Beach, CA 90254
Phone: 310-372-0560 Fax: 310-372-6067
www.procelnurses.com





PROCEL TUBERCULOSIS SCREENING
QUESTIONNAIRE

Please answer YES or NO to the following:

1. Have you ever been diagnosed with Tuberculosis (TB)? … YES … NO

2. Have you ever had a positive or reactive TB test? … YES … NO

3. Have you had a TB immunization in the past 6 months? … YES … NO

4. Are you taking corticosteriods or immunosuppressive meds? … YES … NO

5. Have you ever had a BCG vaccination? (If yes, year: ______) … YES … NO

6. Have you ever taken any medication for TB? … YES … NO

7. In the past 12 months, have you had any of the following:

… YES … NO Persistent Cough
… YES … NO Night Sweats
… YES … NO Excessive Fatigue
… YES … NO Persistent skin rashes, sores or abscesses
… YES … NO Diarrhea lasting more than 48 hours with blood/mucous in stool

If you have a positive PPD, a baseline chest x-ray is required every 4 years.
Date of last chest x-ray: ______________________ Results: _________________________

PPD POSITIVE DATE: ____________________ INDURATION: __________________


I understand that all employees must have an annual Tuberculosis Screening. I hereby give my
consent for the appropriate tests to be done as indicated.

__________________________________________________________________
First Name Last Name

__________________________________________________________________
Employee Signature Date









LATEX ALLERGY QUESTIONNAIRE




… I DO have a latex allergy
… I DO NOT have a latex allergy
… I DO have a SENSITIVITY TO POWDER and require powder free gloves

My signature below indicates that the above information is correct and I give permission
for this information to be shared with PROCEL for the purpose of staffing placement
with contracting facilities.


__________________________________________________
First Name Last Name

__________________________________________________
Signature Date


There are two basic sets of Infection Control procedures:
* Standard Precautions - which are to be followed with every patient, every time
* Isolation Precautions - followed only for patients with certain diseases or organisms. Patients
in Isolation have a sign on or near the door telling you what is required before entering the room.
STANDARD PRECAUTIONS
Standard precautions are based upon common sense. They apply to the care of all patients, since it's not always
possible to tell who is infectious. The very basics of standard precautions include hand hygiene. Hand hygiene is
the use of soap and water or alcohol gel.
* Wash hands before/after patient care to prevent carrying organisms from one patient to another.
This means that you hands must be in contact with soap and water for a full 15 seconds. Find a
clock with a second hand now and note how long 15 seconds is… its longer than you think! See below.
* Use of alcohol gel on non-visibly soiled hands is now recommended as a substitute for hand washing
Its effective and good for hands.
* Alcohol gel does not kill C difficile spores which cause AB associated diarrhea. Always use gloves
when carrying patients with diarrhea & use soap & water (not alcohol rub) after removing gloves.
* Artificial Nails are not allowed in ANY Health Care Facility. Any material applied or added to the
natural nails to augment or enhance (strenghten and lenghten) the wearer's own fingernails, including
wraps, acrylics, extenders, overlays, gels, tips, and any item that is glued or pierced through the
nail. (AORN, 2002 Standards, Recommended Practices, and Guidelines).
* Natural nails: nails without artificial covering other than fresh nail polish.
* Fresh Nail Polish: nail polish that is not obviously chipped or worn for more than four days
(AORN, 2002 Standards, Recommended Practices, and Guidelines).
I. HAND HYGIENE
It may seem basic, simple, easy to do; yet inadequate hand hygiene is one of the most common reasons that
patients get infections.
CATERGORIES
These recommendations are designed to improve hand-hygiene practices of health care workers and to reduce
transmission of pathogenic microorganisms to patients and personnel in health-care settings.
As in previous CDC/HICPAC guidelines, each recommendation is categorized on the basis of exisisting scientific
data, theoretical rationale, applicability, and economic impact. The CDC/HICPAC system for catergorizing
recommendations is as follows:
Catergory IA: Strongly recommended for implementation and strongly supported by well-designed
experimental, clinical or epidemiologic studies.
Catergory IB: Strongly recommended for implementation and supported by certain experimental
clinical or epidemiologic studies and a strong theoretical rationale.
Catergory IC: Required for implementation, as mandated by federal or state regulation or standard
Catergory II: Suggested for implementation and supported by suggestive clinical or epidmiologic
studies or a theoretical rationale.
No recommendation: Unresolved issue. Practices for which insufficient evidence or no consensus
regarding efficacy exsist.
_____________________________________________________________
First Name Last Name
_____________________________________________________________
Signature Date
Hand Hygiene
Hand Hygiene is the single most important infection control activity in a Hospital.
Hand Hygiene Recommendations from CDC








AUTHORIZATION OF RELEASE OF PERSONNEL AND MEDICAL INFORMATION



I, t he under si gned, her eby aut hor i ze Pr ocel Tempor ar y Ser vi ces Inc. t o
pr ovi de my per sonnel and medi cal i nf or mat i on t o Faci l i t i es cur r ent l y
Cont r act ed wi t h Pr ocel , f or t he pur pose of ver i f yi ng t hat I meet t he
r equi r ement s speci f i ed i n t he Agr eement For Tempor ar y St af f i ng of Nur si ng
Ser vi ces. The use of t he i nf or mat i on suppl i ed i s t o be r est r i ct ed t o t he
f or egoi ng st at ed ver i f i cat i on.

Rel ease or t r ansf er of t he speci f i ed i nf or mat i on t o any per son or ent i t y
not speci f i ed her ei n i s pr ohi bi t ed. An addi t i onal wr i t t en consent must be
obt ai ned f or a pr oposed new use of t he i nf or mat i on or f or i t s t r ansf er t o
anot her or ent i t y.

Unl ess ot her wi se st at ed or mandat ed by l aw, t hi s r el ease of i nf or mat i on
consent f or m wi l l not expi r e.


___________________________________________________
Fi r st Name Last Name

___________________________________________________
Si gnat ur e Dat e


NOTICE TO EMPLOYEE

You have a r i ght t o r ecei ve a copy of t hi s aut hor i zat i on.
Revised: 6/30/2010








HEPATI TI S B VACCI NATI ON DECLI NATI ON

I understand that due to my occupational exposure to blood and/or other potentially
infectious materials, I may be at risk of acquiring Hepatitis B (HBV) infection. I have
been given the opportunity to be vaccinated with the Hepatitis B vaccine. However, I
decline the Hepatitis B vaccine at this time. I understand that by declining the vaccine, I
continue to be at risk of acquiring Hepatitis B, a serious disease. If, in the future, I
continue to have occupational exposure to blood and or other potentially infectious
materials and I want to be vaccinated with Hepatitis B vaccine, I can receive the
vaccination series at no charge to me.


__________________________________________
Name

__________________________________________
Signature Date








INFLUENZA VACCINE DECLINATION

Written declination is required by new California Law (SB 739) beginning 2007.


I ACKNOWLEDGE THAT I AM AWARE OF THE FOLLOWING FACTS:

• Influenza is a serious respiratory disease that kills, on average, 36,000 Americans every
year.

• Influenza virus may be shed for up to 48 hours before symptoms begin, allowing
transmission to others.


• Up to 30% of people with influenza have no symptoms, allowing transmission to others.

• Flu virus changes often, making annual vaccination necessary. Immunity following
vaccination is strongest for two (2) to six (6) months. In California, influenza usually
arrives around New Year through February or March.

• I understand that flu vaccine cannot transmit influenza. It does not, however, prevent all
disease. I have declined to receive the influenza vaccine for the 2008-2009 season. I
acknowledge that influenza vaccination is recommended by the CDC for all healthcare
workers to prevent infection from and transmission of influenza and its complications,
including death, to patients, my coworkers, my family and my community.


Please check one of the boxes below:
□ KNOWING THESE FACTS, I CHOOSE TO DECLINE VACCINATION AT THIS
TIME. I may change my mind and accept vaccination later, if vaccine is available. I have read
and fully understand the information on this declination form.

□ I HAVE HAD THE VACCINATION. If you have had the vaccination please provide proof
of the vaccination.

________________________________________________________________________
First Name Last Name

______________
Signature Date


Revised: 12/07/10




Tdap Declination:

I have read and have had an opportunity to review the latest CDC educational
material (Vaccine Information Sheet Tdap) and ask questions regarding: 1)
Tetanus, Diphtheria and Pertussis and their risks to healthcare personnel, and 2) the
potential risk and benefits of the Tetanus, Diphtheria and Pertussis (Tdap) vaccine.

I have elected NOT to receive the Tdap vaccine at this time. I understand that I
may elect to receive the Tdap vaccine at a later time.

I understand I may be at risk of acquiring Pertussis due to my occupational
exposure to aerosol transmissible diseases. I have been given the
opportunity to be vaccinated against this disease or pathogen at my OWN
expense but, I decline the Tdap vaccination at this time. I understand that by
declining the Tdap vaccine, I will continue to be at risk of acquiring a serious
disease. If in the future I want to be vaccinated, I can still receive the Tdap
vaccination at my OWN expense.



_____________________________________________________________________
Name (Please Pr int)



_____________________________________________________________________
Signature Date
poration
heslthcsl"8 staffing BElrW:e
Index: Page Numbers:
1 Qualifications of Procel Temporary Services, Inc. and Mission Statement …………. 1
2 Cultural Diversity ……………………………………………………………………2
3 Continuous Quality Improvement …………..……………………………………………3
4 Patient Safety 2009 ……………………………………………………………………4-5
5 Joint Commission National Patient Safety Goals ……..……………………………….. 6-8
6 Patient Rights ……………………………………………………………………9-11
7 HIPAA Privacy Act and Confidentiality Management …………………………12-13
8 Infection Control: Hand Hygiene and OSHA Regulations …………………………14-18
Standard Precautions
a Hand Hygiene (CDC Guildelines)
b Exposure to blood products
c OSHA's Exposure Control plans
-Bloodbourne Pathogens
-Hepatitis B Virus
-Tuberculosis
9 Safety in the Environment of Care ………………………………………………………. 19-35
a General Safety
b Fire and Life Safety
c Hospital Emergency Preparedness
d Electrical and Medical Equipment Safety
e Patient Fall Prevention
f Utility System Safety
g Hazardous Materials and Material Safety Data Sheets (MSDS)
h Radiation Safety
i Safety and Violence in the Workplace
j Medications Safety
10 Body Mechanics ……………………………………………………………………36-38
11 Restraints and Seclusion …………………………………………………………………. 39-42
12 Age Specific Related Care …………………………………………………………………43-46
13 Pain Assessment and Management ………………………………………………….. 47-48
14 Advance Directives, Capping and Organ Donation …………………………………… 49-50
15 Suspected Abuse ……………………………………………………………………51-56
a Suspected Child Abuse and Neglect
b Suspected Abuse of Elders and Dependent Adults
c Domestic Violence
16 Abbreviations: Joint Commission Official "Do Not Use" List …………………………57
1 Team Dynamics ……………………………………………………………………58
2 Corporate Compliance and Reporting to the Joint Commission ………………………. 59-62
3 Terms of Employment and Job Descriptions ………………………………………53
a. Job Description Registered Nurse ………………………………………64-65
Orientation and Annual Educational Updates
RN's, LVN's, RT's, TECH's, Social Workers and CNA's
Employee Handbook
Our orientation manual can be viewed by CD or on our website at www.procelnurses.com. From the
website go to Employee Forms and select the Orientation Manual document.

Procel Temporary Services, Inc.
Orientation Index Continued:
b. Job Description Registered Nurse/Operating Room …………………………66
c. Job Description Licensed Vocational Nurse ………………………………………67-68
d. Job Description Certified Nursing Assistant ………………………………………69
e. Job Description Operating Room Technician ………………………………………70
f. Job Description Instrument Technician ………………………………………71
g. Job Description Respiratory Therapist ………………………………………72-73
h. Job Description Case Manager ……………………………………………………74-75
i. Job Description Medical Social Worker ………………………………………76
4 Per Diem Policies and Procedures ………..……………………………………………77
5 Floating Policy ……………………………………………………………………78
6 Dress Code and Hand Hygiene Policy, etc. ………………………………………79
7 Workers Compensation Benefits ………..……………………………………………80
8 Harassment Prevention Policy ………..……………………………………………81-83
9 Personnel Counseling Policy ………..……………………………………………84
10 Community Emergency Prevention ………..……………………………………………85
I have thoroughly and completely read and understand the Orientation and/or Annual Education provided.
I have been given the opportunity to seek clarification on any information that I may have had questions.
I understand a copy of this acknowledgement will be placed in my file.
__________________________________________________
First Name Last Name
__________________________________________________ __________________
Employee Signature Date
Procel Temporary Services, Inc.



CODE OF BUSI NESS ETHI CS

PROCEL Daily Mission: Is to earn our customers business for life by exceeding their
expectations and delighting them with our service.
•PROCEL believes in providing prompt and courteous service to all Nurses, Technicians and
Client Facilities.
•PROCEL supports and encourages partnerships with Client Facilities and Nurses through
teamwork and collaboration.
•PROCEL values honesty, confidentiality and mutual respect.
•PROCEL facilitates clear and continuous communication with Staff Nurses, Technicians and
Facility Staff.
•PROCEL participates in comprehensive Quality Improvement Program that addresses
Operations, Practice, and Safe Patient Care.
•PROCEL recognizes and supports the Patient Bill of Rights.
•PROCEL believes in an environment that promotes practice and productivity, encourages
excellence and provides for growth.
•PROCEL contributes to the success of our Clients and Nurses through active Partnership and
through commitment to the success of our Organization.
•PROCEL is dedicated to providing Facilities with Nurses and Technicians who demonstrate
compassionate and safe patient centered care.
•PROCEL believes patients are individuals who have needs arising from conditions, feels and
situations, which they are currently unable to deal with independently.
•PROCEL provides PROfessionals who exCEL in their clinical practice and who make a
difference in how care is delivered to patients in all Clinical settings.
•PROCEL Corporal Employees have the responsibilities to insure through a clinical screening
process, that all Nurses and Technicians have met Procel’s hiring standards.
•PROCEL strives to achieve the highest standard of clinical practice and an excellent reputation
amongst Healthcare Facilities.
•PROCEL is dedicated to full compliance with Regulations Agencies; JCAHO, EEOC, OSHA,
State and Federal.

Joint Commission standards relate to quality and safety of care issues. Anyone believing that he
or she has pertinent and valid information about such matters related to patient quality and patient
safety issues may provide input to the Joint Commission by submitting a complaint to the Office
of Quality Monitoring at:
Division of Accreditation Operations
Office of Quality Monitoring
Joint Commission on Accreditation of Healthcare Organizations
One Renaissance Boulevard
Oakbrook Terrace, IL 60181
Faxed to (630) 792-5636 or E-mailed to compliant@jcaho.org

I have reviewed the PROCEL Code of Ethics and I know how to contact Joint Commission.

_____________________________________________________________
First Name Last Name

______________________________________________________________
Employee Signature Date
PROCEDURE:
Date:
Approved by:
NEEDS OF DYING PATIENTS AND End of Life Care
111912009 Supersede: 101112009
~~iiJ Date:~
Needs of Dying Patients and End of Life Care
Learning Objectives:
After reading this section on Needs of Dying Patients and End of Life Care,
the learner will be able to:
1. Discuss the need to meet physical, spiritual and emotional
needs of the dying patient.
2. State resources available to help meet the needs of the dying
patient.
PROCEL Nurses is committed to caring for patients all the days of their
lives. Part of the care includes end of life care.
We believe:
1.
2.
3.
4.
That it is our responsibility to meet the needs of the dying
patient, physically, spiritually and emotionally.
That excellent culturally competent end of life care is the
physical, emotional and spiritual care we provide to our
patients in the last year of their lives, not the last days.
That pain and symptom management is every patient's
right along with education about their disease process.
That patients often require additional support in the last
years and months of life and to meet this need, our nurses
may participate in Palliative Care and Hospice.
PROCEDUR:
Date:
Approved by:
NEEDS OF DYING PATIENTS AND End of Life Care
11/9/2009 Supersede: 10/1/2009
~~¿i Date:~
Needs of Dying Patients and End of Life Care
Learning Objectives:
After reading this section on Needs of Dying Patients and End of Life Care,
the learner wil be able to:
1. Discuss the need to meet physical, spiritual and emotional
needs of the dying patient.
2. State resources available to help meet the needs of the dying
patient.
PROCEL Nurses is committed to caring for patients all the days of their
lives. Part of the care includes end of life care.
We believe:
1.
2.
3.
4.
That it is our responsibility to meet the needs of
the dying
patient, physically, spiritually and emotionally.
That excellent culturally competent end of life care is the
physical, emotional and spiritual care we provide to our
patients in the last year of their lives, not the last days.
That pain and symptom management is every patient's
right along with education about their disease process.
That patients often require additional support in the last
years and months of life and to meet this need, our nurses
may participate in Palliative Care and Hospice.
Our Nurses are encouraged to read Kubler-Ross E. On death and dying:
What the dying have to teach doctors, nurses, clergy and their families: 1st
ed. New York: Simon and Schuster, 1997
The Needs of the Dying
1. The need to be treated as a living human being.
2. The need to maintain a sense of hopefulness, however changing
its focus may be.
3. The need to be cared for by those who can maintain a sense of
hopefulness, however changing this may be.
4. The need to express feelings and emotions about death in one's
own way.
5. The need to participate in decisions concerning one's care.
6. the need to be cared for by compassionate, sensitive,
knowledgeable people.
7. the need for continuing medical care, even though the goals
may change from "cure" to "comfort" goals.
8. The need to have all questions answered honestly and fully.
9. The need to seek spirituality.
10. The need to be free of physical pain.
11. The need to express feelings and emotions about pain in one's
own way.
12. The need of children to participate in death.
13. The need to understand the process of death.
14. The need to die in peace and dignity.
15. The need not to die alone.
16. The need to know that the sanctity of the body will be respected
after death.
Our Nurses are encouraged to read Kubler-Ross E. On death and dying:
What the dying have to teach doctors, nurses, clergy and their families: 1 st
ed. New York: Simon and Schuster, 1997
The Needs of the Dying
1. The need to be treated as a living human being.
2. The need to maintain a sense of hopefulness, however changing
its focus may be.
3. The need to be cared for by those who can maintain a sense of
hopefulness, however changing this may be.
4. The need to express feelings and emotions about death in one's
own way.
5. The need to participate in decisions concerning one's care.
6. the need to be cared for by compassionate, sensitive,
knowledgeable people.
7. the need for continuing medical care, even though the goals
may change from "cure" to "comfort" goals.
8. The need to have all questions answered honestly and fully.
9. The need to seek spirituality.
10. The need to be free of physical pain.
11. The need to express feelings and emotions about pain in one's
own way.
12. The need of children to participate in death.
13. The need to understand the process of death.
14. The need to die in peace and dignity.
15. The need not to die alone.
16. The need to know that the sanctity of the body wil be respected
after death.
I have read the above Procel policy and procedure for meeting the needs of
dying patients and end of life care.
___________________________________ ________________________
Employee Signature Date
JCAHO CERTI FI ED
2447 Paci fi c Coast Highway, Suite #207 Her mosa Beach, Califor ni a 90254 P: 310-372-0560 F: 877-707-5576
www.pr ocelnurses.com











HI PAA Awar eness Tr aining


I certify that I have received HIPAA Awareness Training. I understand it represents
mandatory policies of the organization and agree to abide by it.


____________________________________________________
First Name Last Name

____________________________________________________
Signature Date

Pr ocel Tempor ar y Ser vices, I nc.

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Score:
Test Name: Comprehensive Core Competency - Nursing
1. The cycles of domestic violence includes incident, tension building, making-up, and calm.
A. True
B. False
2. Seniors who are abusive to their caregivers can increase the caregiver's stress levels and has been known to contribute to abuse and
neglect.
A. True
B. False
3. Some other names for Advance Directives are: Out of Hospital DNR, Medical Power of Attorney, Living Will.
A. True
B. False
4. It is a federal law that adults over 18 years of age have the right to make their own healthcare decisions, including the right to decide
what medical care or treatment to accept, reject or discontinue.
A. True
B. False
5. When explaining a procedure to a preschooler it is okay to use technical medical terms.
A. True
B. False
6. For adults you should encourage as much self care as possible.
A. True
B. False
7. The following are guidelines for transferring patients from a dialysis chair to a wheelchair, EXCEPT:
A. Lock the wheels
B. The patient should hold your waist
C. Face the patient and spread your legs to increase support base
D. Lower the patient into the wheelchair by slowly flexing your knees
8. All of the following natural curves are present in a normal spine, EXCEPT:
A. Cervical
B. Lumbar
C. Thoracic
D. Abdominal
9. A care plan should include discharge planning instructions.
A. True
B. False
10. Completing a comprehensive assessment is the first step in the care planning process.
A. True
B. False
Name:_____________________________________________ CIass:______
Date:___________________________
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11. Even if you are able to resolve a complaint, the supervisor should be notified of the issues.
A. True
B. False
12. Verbal or written complaints concerning abuse or neglect are considered a grievance.
A. True
B. False
13. It is okay for companies to give the hospital free products that the hospital charges the patients for.
A. True
B. False
14. You should always consider your patient's and their family's beliefs when giving your patient a bed bath.
A. True
B. False
15. It is important to understand how a patient interacts with their family when taking care of them.
A. True
B. False
16. Medical Equipment must be inspected every five years.
A. True
B. False
17. All healthcare facilities use the same name for emergency and disaster codes.
A. True
B. False
18. You can find information on proper chemical storage in the Material Safety Data Sheets (MSDS).
A. True
B. False
19. The practicing of Autonomy is difficult for us when our patients choose alternatives that are in conflict with our own value system.
A. True
B. False
20. The underlying core value of the Americans with Disabilities Act is based on the principle of:
A. Veracity
B. Justice
C. Respect for others
D. Autonomy
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21. Which of the following is a contributing factor to a fall?
A. Bed Rails
B. Restraints
C. Brakes
D. All of the above
22. Side effects of some medications can increase a patient's risk for a fall.
A. True
B. False
23. Accessible Protected Health Information (PHI) is limited to only information needed for performance of services.
A. True
B. False
24. It is acceptable to disclose to any third party, the identity of any physicians that have treated or are treating a patient.
A. True
B. False
25. If a patient has C. Diff, the best source to wash your hands with is:
A. Alcohol based soap
B. Soap and warm water
26. A patient is admitted with a positive stool culture for Salmonella. Which of the following types of transmission based precautions must
be followed?
A. Contact precautions
B. Airborne precautions
C. Droplet precautions
D. None of the above
27. Why are healthcare workers at higher risk for developing latex allergy?
A. Higher exposure to latex due to glove usage
B. Women are more prone to develop latex allergy and mostly women work in healthcare
C. They use more soap than others because of frequent hand washing
28. If a patient tells you they have a latex allergy, you should:
A. Call the doctor to discharge them immediately
B. Not wear gloves when caring for them
C. Put them on latex precautions
29. Standards of Care are established by:
A. State Boards of Clinical Disciplines
B. Professional Organizations
C. Policies and Procedures
D. All of the Above
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30. Your best defense in any legal issue is:
A. Strong documentation
B. A good memory
C. Being certified in your field
31. Your facility's Exposure Control Plan is designed to protect all employees.
A. True
B. False
32. Moderate pain corresponds to which number on the numerical pain scale?
A. 10
B. 5
C. 8
D. 2
33. The assessment of pain is an interdisciplinary process including physicians, nurses, physical therapists, and other clinical disciplines
involved with the patient's care.
A. True
B. False
34. Respect for the patient's psychological, spiritual, and cultural values in the healthcare setting is important since it affects how the patient
will respond to their care.
A. True
B. False
35. Patients have the right and responsibility to report perceived risk of their care and/or safety issues or concerns they, as patients, may
have.
A. True
B. False
36. Accredited institutions are required to conduct a patient safety survey of the staff annually.
A. True
B. False
37. Medication errors and adverse drug reactions are included in the scope of the patient safety plan.
A. True
B. False
38. Hospitals are required to perform how many FMEA(s) a year?
A. One
B. Two
C. Five
D. Ten
39. Quality Improvement focuses on collecting data.
A. True
B. False
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40. Restraints can cause the patient's level of anxiety and confusion to increase.
A. True
B. False
41. Monitoring of restrained patients consists of documenting behavior, addressing basic needs, and attempting or addressing alternatives.
How often is this required?
A. Every hour
B. Every 2 hours
C. Every 4 hours
D. Once a shift
42. Risk Management is important to healthcare facilities in order to:
A. Reduce costs
B. Improve care
C. Protect employees
D. All of the above
43. Incident reports should NOT be placed in the patient's medical record.
A. True
B. False
44. Aggressive behavior may occur between:
A. Families and staff
B. Patients and families
C. Staff and patients
D. All of the above
45. Zero tolerance is a policy outlining what is and is not acceptable behavior in the workplace.
A. True
B. False
46. One sign that a nurse may be impaired is when patients complain that pain medication is not effective or deny receiving medication
during that nurse's shift.
A. True
B. False
47. There are three major categories of impairment - alcoholism, drug addiction, and mental health disorders.
A. True
B. False
48. You do not have to be the one being harassed to be a victim of sexual harassment.
A. True
B. False
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49. If you feel you are being sexually harassed, you should first:
A. Tell the harasser that their conduct is unwelcomed
B. Tell your supervisor
C. Just quit and find another job
50. Medicare/Medicaid providers are required to conduct employee training on Compliance.
A. True
B. False
Date: _
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Score:
Test Name: Moderate Sedation
1. The primary goal of moderate sedation is to eliminate patient pain/discomfort during planned procedures.
A. True
B. False
2. When managing a patient receiving moderate sedation, the nurse should monitor all of the following EXCEPT:
A. Vital signs
B. Blood gases
C. Level of consciousness
D. Skin condition
3. Which of the following statements about midazolam (Versed) is true?
A. Is a potent respiratory depressant
B. Excessive doses may lead to agitation and involuntary movement
C. May be reversed with flumazenil (Romazicon)
D. All the above are true
4. Vital Signs during a procedure should be recorded, how often?
A. every 5 minutes
B. every 10 minutes
C. every 15 minutes
D. None of the above
5. Moderate sedation/analgesia is a drug-induced depression of consciousness during which patients respond purposefully to verbal
commands.
A. True
B. False
6. Patients receiving moderate sedation do not need vascular access during the procedure.
A. True
B. False
7. The nurse monitoring a patient should be able to demonstrate acquired knowledge of:
A. Pharmacology of drugs used for moderate sedation/analgesia
B. Cardiac arrhythmia interpretation
C. Principles of oxygen delivery
D. All of the above
8. Patients may be discharged by the post-procedural caregiver when:
A. Respirations are greater than 12
B. All discharge criteria are met
C. Thirty minutes have elapsed post-procedure
D. The patient is pain free
9. An informed consent must be signed prior to the administration of sedation.
A. True
B. False
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Test Name:
Date: _
Score:
Moderate Sedation
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10. In the post-procedure phase, the patient will have q 15 minute vital signs until an Aldrete score of at least 9 and/or a pre-sedation level
of consciousness/activity has been achieved.
A. True
B. False
11. Patients may not be discharged for a minimum of 1 hour following the procedure unless specifically ordered by the physician.
A. True
B. False
12. Intravenous drugs should be given in small, incremental doses that are titrated to the desired end points.
A. True
B. False
13. For patients receiving IV push sedation, a physician does not need to be present during the administration of the medication.
A. True
B. False
14. The response of patients to commands during procedures performed with moderate sedation serves as a guide to their level of
consciousness.
A. True
B. False
Date:
No electronic signature on record. Page 1 of 2
Score:
Test Name: EMTALA
1. What do the letters EMTALA stand for?
A. Emergency Medical Treatment And Labor (meaning pregnant women who are in labor) Act
B. Emergency Medical Transitional Labor (meaning pregnant women who are in labor) Act
2. The goal of the EMTALA law is to:
A. Protect the financial health of the hospital
B. Protect the public from fraud
C. Prevent discrimination in health care
D. Ensure free health care for all
3. With regards to the EMTALA law and your work, which of the following statements reflects the law’s impact on your?
A. I may be in a position to deal with patients who come to the hospital for urgent care and I want to make sure that everything
I say to the patient is compliant with EMTALA rules.
B. I want to provide safe and compassionate care to all who come to the hospital regardless of their ability to pay.
C. If I break EMTALA rules, even without the intention to break the rules, the hospital might suffer grave consequences.
D. All of the above.
4. There are many different types of patients who may be covered by the EMTALA rules. Which of the following are appropriate?
A. Anyone who presents to the ED with a complaint.
B. Anyone who brings up an urgent condition even if that person is not present in the ED but in another area of the hospital
and/or visiting a friend/family.
C. Anyone in active labor.
D. All of the above.
5. EMTALA laws mandate what we must provide for patients who are covered by EMTALA rules. Select the answer that does NOT apply.
A. Health insurance at no cost to the patient
B. A free transfer to another facility
C. A medical screening exam by a qualified medical provider
D. Any treatment required to stabilize the patient
6. When is it safe to ask about insurance for any patient who comes to the ED?
A. Never.
B. When the patient first comes to admissions, so we can be sure to follow all the rules.
C. After the medical screening exam has been completed.
D. Only if the patient is admitted as an inpatient at the hospital.
7. Can we transfer a patient covered by EMTALA rules?
A. Yes, if we have permission from the receiving hospital and the qualified medical provider at the hospital provides a
written certification that the benefits of transfer outweigh the risks of staying at the hospital.
B. Yes, especially if the patient has Medi-Cal insurance since the hospital is not a Medi-Cal provider.
C. No, we can never transfer a patient who is covered by EMTALA rules.
8. What happens if we do not abide by the EMTALA rules?
A. Nothing
B. Not much
C. Fines, loss of the ability to care for Medicare patients.
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Name: _
Score:
Test Name: EMTALA
Date: _
No electronic signature on record. Page 2 of 2
9. Emergency Department Scenario A young couple arrives to the ED carrying a newborn infant, handing the RN a form from a neighboring
clinic directing them to another neighboring hospital for sick infant with 103 fever. Family is directed into Triage, baby is examined and vital
signs taken. Temperature 103, baby lethargic, parents upset. The father asks if the hospital they are now in is the neighboring hospital. In
the above scenario the most appropriate response by the nurse is:
A. No, it isn’t.
B. This is ABC Hospital and a Physician will see your baby shortly.
C. No, it isn’t and we do not admit children.
D. This is ABC Hospital and we do not admit children.
10. In the above scenario, the physician sees baby, medication given and hydration given with improvement. When the baby is ready for
discharge the family was referred back to the clinic they came from for follow up. The nurse tells the family, “Bring your baby back to the
nearest Emergency Room if symptoms reoccur”. Did the nurses stay within limits of EMTALA rules and regulations?
A. Yes
B. No
11. Emergency Department Scenario A 23 year old women presents to the Emergency Department at 0500 asking, “Is this XYZ Hospital?
Do you have rape kits?” The triage RN states, “No. This is ABC Hospital and we do not have rape kits here. However our physician will
give you a medical screening exam and transfer you to XYZ Hospital.” Patient replies, “I would rather drive my own car over to XYZ
Hospital rather than wait here and get transferred.” Nurse documents this on her triage note. Have we violated EMTALA rules? In the
above scenario, were the EMTALA rules violated?
A. Yes. The initial information provided to the patient was not focused on the necessary initial medical screening (MSE)
but on the “We don’t provide that level of care and you will just be sent elsewhere anyway”. The information provided gave
the patient the “I don’t want to wait and/or I shouldn’t wait option”, thus violating the EMTALA law.
B. No. The patient was provided factual answers to her questions and offered a medical screening exam and was informed regarding
her eventual transfer. She decided to leave before the MSE.
Date: _
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Score:
Test Name: Emergency Room
1. An elderly patient is brought to the Emergency Room after falling at home. The patient complains of severe pain in the hip and an inability
to walk. To assess for a hip fracture, the nurse would:
A. Observe for bruising over the affected hip
B. Observe for shortening of the affected leg
C. Move the affected leg to see whether it causes pain
D. Move the affected leg to feel and hear crepitus
2. A patient is admitted to the Emergency Room with multiple injuries including a crushed chest, abdominal trauma, probable head injury,
and multiple fractures. In order of priority, the initial emergency care interventions for this patient are to:
A. Conduct a thorough physical assessment, assess vital signs, and cover open wounds
B. Assess vital signs, control accessible bleeding, and determine the presence of critical injuries
C. Start an IV, get blood for typing and cross matching, and obtain a history
D. Assess vital signs, obtain a history, and arrange for emergency x-ray films
3. After an accident in which there is a question of back injury, the individual involved:
A. Can be transported in sitting position
B. May be transported best when placed in a side-lying position
C. Should be protected from flexion and hyperextension of the spine
D. May be transported in any position because position in not important
4. A child who was found face down in a water ditch is brought to the Emergency Room. The child, who has a pulse of 50 beats per minute
but no spontaneous respirations, is intubated and bagged with 100% oxygen. The most important nursing measure at this time is to:
A. Start an IV to provide fluid and electrolytes
B. Assist the physician in delivering intracardiac medications
C. Suction the endotracheal tube, mouth, and nasal passages
D. Call the pediatric ICU to inform them of the child’s admission
5. A patient is admitted to the Emergency Room with head and chest injuries received in an automobile accident. When evaluating the
patient’s response to the Emergency Room treatments, which assessments indicate that the patient can safely be transferred to a critical
care unit?
A. Alert but restless, stable vital signs, and cyanosis
B. Stable vital signs, apprehension, and complaints of pain
C. Drowsy but easily aroused, improving tissue perfusion, and fluctuating vital signs
D. Elevated temperature, slowing pulse and respirations, and pain in the injured extremity
6. During the initial assessment of a 70-year-old male who is being re-admitted with hematemesis and bright-red rectal bleeding, the nurse
should be particularly alert for:
A. Facial flushing
B. Petechiae
C. Pruritus
D. Hypertension
7. The nurse knows that a patient on long term anticoagulant therapy must be carefully monitored for potential hemorrhage complications
that most commonly affect the:
A. GI Tract
B. Genitourinary tract
C. Respiratory tract
D. Capillary vasculature
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Name: _
Test Name:
Date: _
Score:
Emergency Room Competency Exam
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8. Which sign is typically the first indication of increased ICP?
A. Elevated systolic blood pressure
B. Elevated body temperature
C. Altered respiratory pattern
D. Altered level of consciousness
9. Which condition commonly mimics the signs and symptoms of alcohol intoxication?
A. Diabetic reactions
B. Head injury
C. Drug overdose
D. All of the above
10. Which symptom of cocaine abuse would the nurse expect to detect during a patient assessment?
A. Lethargy and obtundation
B. Constricted pupils
C. Hypothermia and tiredness
D. Euphoria and restlessness
11. The major objective during the emergent phase of a burn is to:
A. Relieve pain
B. Prevent infection
C. Replace blood loss
D. Restore fluid volume
12. Which treatment would the nurse expect a physician to order for a suspected cocaine overdose patient?
A. Oxygen
B. Naloxone
C. Physostigmine
D. Activated charcoal
13. The goals of triage include all of the following EXCEPT:
A. Control of patient flow through the emergency department.
B. Assignment of patients to appropriate care areas within the emergency department
C. Performing and documenting secondary survey on all patients who come to triage
D. Determination of the urgency of the patient's condition.
14. A patient is receiving intravenous potassium chloride for the treatment of hypokalemia. Which of these rhythm strip changes should the
nurse expect to observe if the patient develops hyperkalemia?
A. Shortened PR interval
B. Peaked T waves
C. Prominent U wave
D. Elevated ST segment
15. A clinical sign that would indicate a child is suffering severe dehydration is:
A. The presence of excessive drooling
B. The absence of tears
C. A slightly increased respiratory rate
D. A slowed heart rate
Name:
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Test Name:
Oate: _
Score:
Emergency Room Competency Exam
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16. A patient complains of a sudden headache one minute after a drug is administered. Which of the following drugs would MOST LIKELY
cause this symptom?
A. Lidocaine
B. Quinidine
C. Nitrates
D. Digoxin
17. Which of the following assessment parameters may be used by the emergency department nurse to evaluate the toxicity of an
acetaminophen poisoning?
A. Liver Function Test
B. Serial arterial blood gases
C. Coagulation studies
D. Electrolytes
18. Methods that the emergency room nurse may use to reinforce discharge instructions include:
A. Give only oral instructions when discharging a patient from the ER
B. Tell the patient to call their physician or nurse practitioner if there is anything they do not understand about their
care in the emergency room
C. Involve the patient's family or significant others (with patient consent) with the discharge instructions that are being
given to the patient
D. If the patient does not speak English, encourage him/her to contact a translator when he/she returns home to explain
the instructions to him
19. When establishing and maintaining adequate airway, breathing, and circulation for trauma victims, the emergency nurse should give
equal priority to:
A. Assessing the patient's neurological status
B. Identifying all injuries
C. Maintaining cervical spine precautions
D. Assessing vital signs
20. Your patient is on a ventilator. The low volume alarm sounds. This may be due to:
A. Pulmonary edema
B. Decreased secretions
C. A disconnected tube
D. Biting the tube
21. Which of these medications in a patient's history would be associated with hematemesis?
A. Hydromorphone hydrochloride (Dilaudid)
B. Acetaminophen (Tylenol)
C. Meperidine hydrochloride (Demerol)
D. Ketorolac tromethamine (Toradol)
22. A 15-year-old boy who was stacking wood 2 days ago presents to the emergency department complaining of a painful ulceration on the
dorsal surface of the second digit of his right hand. He has no other complaints. Based on this history, the most likely thing that may have
bitten him is:
A. Back widow spider
B. Blue scorpion
C. Brown recluse spider
D. Wolf spider
Name: _
Test Name:
Oate: _
Score:
Emergency Room Competency Exam
Nationally Validated Content - Copyright © 2010 Clearview Staffing Software Inc. Page 4 of 5

23. A late sign or symptom of hyponatremia is:
A. Hypertension
B. Hyperactivity
C. Seizure activity
D. Neck vein distention
24. One of the best ways to prevent misinterpretation of patient care situations is to:
A. Clearly and concisely document what happened
B. Call the supervisor to witness any unusual events
C. Ask the physician to add information to their dictation
D. Complete an exception report as a routine part of the chart
25. An injury where skin is peeled away from an extremity is:
A. Contusion
B. Laceration
C. Abscess
D. Avulsion
26. When using active external re-warming devices, caution must be exercised to prevent:
A. Additional vasoconstriction in the affected extremities from the application of heat
B. Decrease in patient's core body temperature from the application of heat
C. Injury to the patient's skin from heat application because of the initial peripheral vasoconstriction
D. The development of hypertension from heat application
27. When a child presents to the ER and abuse or neglect is suspected, the emergency nurse must:
A. Notify the parents about her concern
B. Report to the appropriate authorities
C. Obtain the appropriate consent for further treatment
D. Consult with an attorney to protect herself from a lawsuit
28. The nurse's most immediate concern for a patient sustaining a LeFort fracture should be:
A. Tooth loss
B. Airway management
C. Tooth malocclusion
D. Uncontrolled epistaxis and resultant hypovolemia
29. The purpose of charcoal in the care of the poisoned patient is to:
A. Absorb toxins from the gastrointestinal tract
B. Induce vomiting and remove all the remaining toxins
C. Prevent cardiac dysrhythmia that may result from absorbed toxins
D. Decrease the possibility of bleeding from the absorbed toxins
30. What specific physical signs may indicate respiratory distress in the adult asthmatic patient?
A. Paroxysmal coughing
B. Sternocleidomastoid retractions
C. Audible wheezing
D. Nausea and vomiting
Name:
-------------------------------
Test Name:
Date: _
Score:
Emergency Room Competency Exam
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31. Name this rhythm:
A. 1st degree heart block
B. Normal sinus rhythm
C. 3rd degree heart block
D. Bradycardia
32. A 24-year-old woman complains of crampy pain in the right lower quadrant for the past several hours. She denies nausea, vomiting, or
diarrhea but reports moderate spotting over the past 24 hours. Her last menstrual period was 2 months before the onset of symptoms. Her
vital signs include blood pressure of 124/84, P 90, and temperature 98.8 degrees. Based on these assessment findings, the emergency
nurse should suspect:
A. Dysmenorrhea
B. Endometriosis
C. Ectopic pregnancy
D. Ruptured ovarian cyst
33. What is the principal cause of a radial head dislocation in children?
A. A pull on a pronated forearm
B. A fall onto an outstretched forearm
C. A blow to pronated forearm
D. A crush injury to a supinated forearm
34. Respiratory syncytial virus (RSV) is NOT transmitted by:
A. Large droplet aerosols
B. Sneezing
C. Visitors
D. Hand washing
Date: _
Nationally Validated Content - Copyright © 2010 Clearview Staffing Software Inc. Page 1 of 6

Score:
Test Name: Emergency Room Medication
1. The nurse knows that a patient on long term anticoagulant therapy must be carefully monitored for potential hemorrhage
complications that most commonly affect the:
A. GI Tract
B. Genitourinary tract
C. Respiratory tract
D. Capillary vasculature
2. A patient complains of a sudden headache one minute after a drug is administered. Which of the following drugs would
MOST LIKELY cause this symptom?
A. Lidocaine
B. Quinidine
C. Nitrates
D. Digoxin
3. Which of the following assessment parameters may be used by the emergency department nurse to evaluate the toxicity of
an acetaminophen poisoning?
A. Liver Function Test
B. Serial arterial blood gases
C. Coagulation studies
D. Electrolytes
4. Which of these medications in a patient's history would be associated with hematemesis?
A. Hydromorphone hydrochloride (Dilaudid)
B. Acetaminophen (Tylenol)
C. Meperidine hydrochloride (Demerol)
D. Ketorolac tromethamine (Toradol)
5. A patient is receiving intravenous potassium chloride for the treatment of hypokalemia. Which of these rhythm strip
changes should the nurse expect to observe if the patient develops hyperkalemia?
A. Shortened PR interval
B. Peaked T waves
C. Prominent U wave
D. Elevated ST segment
6. A patient with a history of hypertension comes to the Emergency Room with double vision and a blood pressure of 260/120
mm Hg. In addition to other drugs, the physician orders a Sodium Nitroprusside infusion. The nurse recognized that
this drug decreases blood pressure by:
A. Increasing cardiac output
B. Decreasing the heart rate
C. Increasing peripheral resistance
D. Relaxing venous and arterial muscles
7. A patient brought to the Emergency Room develops premature ventricular Beats (PVBs) after arrival. The nurse should
anticipate that the patient would receive:
A. Epinephrine
B. Atropine Sulfate
C. Sodium Bicarbonate
D. Lidocaine Hydrochloride
k~ãÉW|||||||||||||||||||||||||||||||||||||||||||
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Name: _
Test Name:
Date: _
Score:
Emergency Room Medication
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8. The physician orders a heparin infusion. He orders 25,000 units of heparin in 500 ml of dextrose 5% in water (D5W) to
infuse at the rate of 1,000 units/hr. The flow rate in milliliters per hours is:
A. 12 mls per hour
B. 24 mls per hour
C. 20 mls per hour
D. 6 mls per hour
9. The order reads: Bumex 5 mg IV. Bumex is available in 0.25 mg/ml vials. How many ml's would you give?
A. 12.5 mls
B. 2 mls
C. 125 mls
D. 20 mls
10. The order reads: Haldol 1 mg IV. Haldol is available in a 5mg/ml ampule. How many ml's would you give?
A. 0.1 ml
B. 0.2 ml
C. 1 ml
D. 2 ml
11. The order reads: Tylenol elixir 350 mg via NGT. Tylenol elixir is available in 80 mg/5ml bottles. How many ml's would
you give?
A. 2.18 mls
B. 21 mls
C. 218 mls
D. 21.8 mls
12. The drug of choice for a pregnant patient who has seizures associated with pregnancy-induced hypertension is:
A. Phenytoin sodium (Dilantin)
B. Magnesium sulfate
C. Diazepam (Valium)
D. Valproic acid (Depakene)
13. The order reads: Synthroid 0.75mgIV. Synthroid is available in 500mcg/ml vial. How many ml's would you give for this
dose?
A. 15ml
B. 1.5 ml
C. 0.15ml
D. 150 ml
14. A 154lb patient has been sedated and is now being paralyzed with vecuronium bromide (Norcuron). The recommended initial
dose is 0.1 mg/kg. The available 10 ml vial of Norcuron containes 1 mg/ml. How many milliliters shoud the patient
receive?
A. 0.07 ml
B. 7 mg
C. 0.7 ml
D. 15.4 ml
Name:
-------------------------------
Test Name:
Date: _
Score:
Emergency Room Medication
Nationally Validated Content - Copyright © 2010 Clearview Staffing Software Inc. Page 3 of 6

15. An infusion of phenytoin (Dilantin) at a rate greater than 50 mg/min for an adult may result in which of these side
effects?
A. Tachypnea
B. Bradycardia
C. Hypertension
D. Tachycardia
16. The order reads: Vancomycin 15 mg/kg over 1 hour x1. The patient weighs 60 kg. How many mg will be given?
A. 1000 mg
B. 90 mg
C. 900 mg
D. 600 mg
17. A female patient diagnosed with a urinary tract infection (UTI) is being discharged from the emergency department and
will be treated with ampicillin and phenazopyridine. The emergency nurse should instruct the patient that phenazopyridine
would:
A. Decrease her needs for drinking additional fluids
B. Turns her urine orange
C. Treat her fever and chills
D. Take several days to be effective
18. One indicator of myocardial reperfusion during thrombolytic therapy is:
A. Relief of chest pain
B. Q waves less than 0.04 seconds in width
C. Prothrombin time greater than 25 seconds
D. Absence of ventricular dysrhythmias
19. The order reads: Digoxin 0.25 mg IV Digoxin is available in a 0.5mg/2ml ampoule. How many ml's would you give for this
dose?
A. 1ml
B. 0.5 ml
C. 2 ml
D. 1 mg
20. Which drug is the treatment of choice to prevent seizure from traumatic head injury?
A. Diazepam
B. Dexamethasone (Decadron)
C. Phenytoin
D. Phenobarbital
21. A child is admitted to the emergency room following ingestion of a bottle of Children's Tylenol. The nurse is aware
that Tylenol poisoning is treated first with:
A. Acetylcysteine
B. Deferoximine
C. Edetate calcium disodium
D. Activated charcoal
Name:
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Test Name:
Oate: _
Score:
Emergency Room Medication
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22. The patient is admitted to the emergency room with shortness of breath, anxiety, and tachycardia. His ECG reveals atrial
fibrillation with a ventricular response rate of 130 beats per minute. The physician orders quinidine sulfate. While
he is receiving quinidine, the nurse should monitor his ECG for:
A. Peaked P wave
B. Elevated ST segment
C. Inverted T wave
D. Prolonged QT interval
23. The patient is admitted from the emergency room with multiple injuries sustained from an auto accident. His physician
prescribes a histamine blocker. The nurse is aware that the reason for this order is:
A. To treat general discomfort
B. To correct electrolyte imbalances
C. To prevent stress ulcers
D. To treat nausea
24. After the administration of epinephrine to a child with asthma, the nurse would carefully monitor for the common side
effect of:
A. Flushing
B. Dyspnea
C. Tachycardia
D. Hypotension
25. When administering an intravenous titrated drip of Lidocaine HCL to a patient, an adverse effect to immediately watch
for is:
A. Tremors
B. Anorexia
C. Tachycardia
D. Hypertension
26. Which of the following is appropriate for acute M.I. treatment?
A. Morphine
B. Oxygen
C. Nitroglycerin
D. All of the above
27. For a patient in P.E.A. (Pulseless electrical activity), which medication would be given first?
A. Dopamine
B. Lidocaine
C. Amiodarone
D. Epinephrine
28. What is the MOST important nursing goal for a patient in septic shock?
A. To promote adequate tissue perfusion and support oxygenation, ventilation, and hemodynamic stability
B. To maintain accurate intake and output records and to optimize support
C. To prevent skin and soft tissue breakdown
D. To promote comfort and provide psychosocial support to the patient and family
Name: _
Test Name:
Date: _
Score:
Emergency Room Medication
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29. When administering medications via the endotracheal tube, the dose should be increased at:
A. 1 to 1.5 times the normal dose
B. 2 to 2.5 times the normal dose
C. 3 to 3.5 times the normal dose
D. 4 to 4.5 times the normal dose
30. All of the following medications may be helpful in the treatment of acute pulmonary edema EXCEPT:
A. Morphine
B. Nitroglycerin
C. Furosemide
D. Epinephrine
31. The physician has ordered an infusion of Osmitrol (mannitol) for a patient with increased intracranial pressure. Which
finding indicates the direct effectiveness of the drug?
A. Increased pulse rate
B. Increased urinary output
C. Decreased diastolic blood pressure
D. Increased pupil size
32. The physician has ordered Activase (alteplase) for a patient admitted with a myocardial infarction. The desired effect
of Activase is:
A. Prevention of congestive heart failure
B. Stabilization of the clot
C. Stabilization of the Vessel Tunica Intima
D. Lysis of the clot
33. Which of the following is a true statement in relation to the positive effects of Morphine Sulfate in a patient who
has experienced a myocardial infarction?
A. Morphine relieves the anxiety a patient feels secondary to a catecholamine release, decreases myocardial workload by
increasing venous capacitance and reducing systemic vascular resistance
B. Morphine relieves anxiety and decreases workload of the heart through a diuretic effect
C. Morphine relieves anxiety and decreases myocardial workload by vasodilating the pulmonary arterial tree
D. Morphine relieves the anxiety a patient feels secondary to a decrease in catecholamine release, decreases myocardial
workload by decreasing venous capacitance and increasing systemic vascular resistance
34. Which of the following drugs is now considered the standard therapy for unstable angina and after treatment of a MI?
A. Ticlopidine (Ticlid)
B. Abciximab (ReoPro)
C. Eptifibatide (Integrilin)
D. Aspirin
35. A patient weighing 40 kilograms is to receive Dopamine at 7 micrograms/kg/min. The dosage available is Dopamine 800
mg to be mixed in 250 ml of Normal Saline. What is the infusion rate?
A. 5.25 ml/hr
B. 10 ml/hr
C. 5 ml/hr
D. 10.5 ml/hr
Name:
-------------------------------
Test Name:
Date: _
Score:
Emergency Room Medication
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36. A patient is admitted to the hospital with pneumonia and congestive heart failure and requires mechanical ventilation.
Which of the following medications would you anticipate the patient receiving?
A. Tetracycline
B. Sodium Bicarbonate
C. Pepcid
D. Mannitol
37. A patient is receiving tenecteplase (TNKase) 3 hours after an acute MI. Which of the following should you immediately
report to the physician?
A. PVC’s
B. Bleeding gums
C. Oozing at the insertion site
D. Change in mental status
38. Your patient is on a Dopamine drip for hypotension. However, the more you increase the Dopamine, the lower the BP drops.
You should consider:
A. Continuing to increase the drip because the patient may need more alpha effect
B. Doing nothing and see if the patient stabilizes
C. Administering additional fluids
D. Giving another more potent drug such as Neosynephrine
39. A child has been diagnosed as having acute acetaminophen (Tylenol) poisoning. Which of these antidotes, if administered,
would bind with the toxic metabolites released from the medication?
A. Acetylcysteine (Mucomyst)
B. Ibuprofen (Advil)
C. Magnesium citrate
D. Syrup of ipecac
40. The order reads: Heparin 1700 units/hr. Premixed Heparin drips are available with Heparin 25,000 units/500ml. how many
ml's per hour would you administer?
A. 580 mls
B. 3.4 mls
C. 58 mls
D. 34 mls
Form W-4 (2012)
Purpose. Complete Form W-4 so that your
employer can withhold the correct federal income
tax from your pay. Consider completing a new Form
W-4 each year and when your personal or financial
situation changes.
Exemption from withholding. If you are exempt,
complete only lines 1, 2, 3, 4, and 7 and sign the
form to validate it. Your exemption for 2012 expires
February 18, 2013. See Pub. 505, Tax Withholding
and Estimated Tax.
Note. If another person can claim you as a
dependent on his or her tax return, you cannot claim
exemption from withholding if your income exceeds
$950 and includes more than $300 of unearned
income (for example, interest and dividends).
Basic instructions. If you are not exempt, complete
the Personal Allowances Worksheet below. The
worksheets on page 2 further adjust your
withholding allowances based on itemized
deductions, certain credits, adjustments to income,
or two-earners/multiple jobs situations.
Complete all worksheets that apply. However, you
may claim fewer (or zero) allowances. For regular
wages, withholding must be based on allowances
you claimed and may not be a flat amount or
percentage of wages.
Head of household. Generally, you can claim head
of household filing status on your tax return only if
you are unmarried and pay more than 50% of the
costs of keeping up a home for yourself and your
dependent(s) or other qualifying individuals. See
Pub. 501, Exemptions, Standard Deduction, and
Filing Information, for information.
Tax credits. You can take projected tax credits into
account in figuring your allowable number of
withholding allowances. Credits for child or
dependent care expenses and the child tax credit
may be claimed using the Personal Allowances
Worksheet below. See Pub. 505 for information on
converting your other credits into withholding
allowances.
income, see Pub. 505 to find out if you should adjust
your withholding on Form W-4 or W-4P.
Two earners or multiple jobs. If you have a
working spouse or more than one job, figure the
total number of allowances you are entitled to claim
on all jobs using worksheets from only one Form
W-4. Your withholding usually will be most accurate
when all allowances are claimed on the Form W-4
for the highest paying job and zero allowances are
claimed on the others. See Pub. 505 for details.
Nonresident alien. If you are a nonresident alien,
see Notice 1392, Supplemental Form W-4
Instructions for Nonresident Aliens, before
completing this form.
Check your withholding. After your Form W-4 takes
effect, use Pub. 505 to see how the amount you are
having withheld compares to your projected total tax
for 2012. See Pub. 505, especially if your earnings
exceed $130,000 (Single) or $180,000 (Married).
Future developments. The IRS has created a page
on IRS.gov for information about Form W-4, at
www.irs.gov/w4. Information about any future
developments affecting Form W-4 (such as
legislation enacted after we release it) will be posted
on that page.
Personal Allowances Worksheet (Keep for your records.)
A Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . . A
B Enter “1” if:
• You are single and have only one job; or
• You are married, have only one job, and your spouse does not work; or . . .

B
C Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more
than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . . . . . . . . . . . .
C
D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . . D
E Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . . E
F Enter “1” if you have at least $1,900 of child or dependent care expenses for which you plan to claim a credit . . . F
(Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)
G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.
• If your total income will be less than $61,000 ($90,000 if married), enter “2” for each eligible child; then less “1” if you have three to
seven eligible children or less “2” if you have eight or more eligible children.
G
H H
For accuracy,
complete all
worksheets
that apply.
• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions
and Adjustments Worksheet on page 2.
• If you are single and have more than one job or are married and you and your spouse both work and the combined
earnings from all jobs exceed $40,000 ($10,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to
avoid having too little tax withheld.
• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.
Separate here and give Form W-4 to your employer. Keep the top part for your records.
Form
Department of the Treasury
Internal Revenue Service
Employee's Withholding Allowance Certificate

Whether you are entitled to claim a certain number of allowances or exemption from withholding is
subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
OMB No. 1545-0074
1 Your first name and middle initial Last name
Home address (number and street or rural route)
City or town, state, and ZIP code
2 Your social security number
3 Single Married Married, but withhold at higher Single rate.
4 If your last name differs from that shown on your social security card,
check here. You must call 1-800-772-1213 for a replacement card.
5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 5
6 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6
$
7 I claim exemption from withholding for 2012, and I certify that I meet both of the following conditions for exemption.
• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and
• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.
If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . .
7
Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.
Employee’s signature
(This form is not valid unless you sign it.) Date
8 Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)
For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 10220Q Form W-4 (2012)
Procel Nurses | 2447 Pacific Coast Hwy Suit e 207 Hermosa Beach, CA 90254
95 4215452
Department of Homeland Security
U.S. Citizenship and Immigration Services
Form I-9, Employment
Eligibility Verification
OMB No. 1615-0047; Expires 06/30/08
Please read instructions carefully before completing this form. The instructions must be available during completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work eligible individuals. Employers CANNOT
specify which document(s) they will accept from an employee. The refusal to hire an individual because the documents have a
future expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Verification. To be completed and signed by employee at the time employment begins.
Print Name: Last First Middle Initial Maiden Name
Address (Street Name and Number) Apt. # Date of Birth (month/day/year)
State City Zip Code Social Security #
A lawful permanent resident (Alien #) A
A citizen or national of the United States
I am aware that federal law provides for
imprisonment and/or fines for false statements or
use of false documents in connection with the
completion of this form.
An alien authorized to work until
(Alien # or Admission #)
Employee's Signature Date (month/day/year)
Preparer and/or Translator Certification. (To be completed and signed if Section 1 is prepared by a person other than the employee.) I attest, under
penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct.
Address (Street Name and Number, City, State, Zip Code)
Print Name Preparer's/Translator's Signature
Date (month/day/year)
Section 2. Employer Review and Verification. To be completed and signed by employer. Examine one document from List A OR
examine one document from List B and one from List C, as listed on the reverse of this form, and record the title, number and
expiration date, if any, of the document(s).
AND List B List C OR List A
Document title:
Issuing authority:
Document #:
Expiration Date (if any):
Document #:
Expiration Date (if any):
and that to the best of my knowledge the employee is eligible to work in the United States. (State (month/day/year)
employment agencies may omit the date the employee began employment.)
CERTIFICATION - I attest, under penalty of perjury, that I have examined the document(s) presented by the above-named employee, that
the above-listed document(s) appear to be genuine and to relate to the employee named, that the employee began employment on
Print Name Title Signature of Employer or Authorized Representative
Date (month/day/year) Business or Organization Name and Address (Street Name and Number, City, State, Zip Code)
B. Date of Rehire (month/day/year) (if applicable) A. New Name (if applicable)
C. If employee's previous grant of work authorization has expired, provide the information below for the document that establishes current employment eligibility.
Document #: Expiration Date (if any): Document Title:
Section 3. Updating and Reverification. To be completed and signed by employer.
l attest, under penalty of perjury, that to the best of my knowledge, this employee is eligible to work in the United States, and if the employee presented
document(s), the document(s) l have examined appear to be genuine and to relate to the individual.
Date (month/day/year) Signature of Employer or Authorized Representative
Form I-9 (Rev. 06/05/07) N
I attest, under penalty of perjury, that I am (check one of the following):
Meal Break Agreement


I understand that I am entitled to one meal period per eight (8) hour shift that I work. I
would prefer to waive my meal break when I work less than six (6) hours per day. I will
continue to take my rest breaks. When I work over six (6) hours in one day, I agree to
take my thirty-minute meal period.


When I work a twelve (12) hour shift, I agree to take a thirty-minute meal period and will
waive a second thirty-minute meal period.


This will be in effect my first day of employment with PROCEL. I understand that I may
revoke this at any time.



_____________________________________________________________
First Name Last Name



_____________________________________________________________
Signature Date






Authorization Agreement for Automatic Direct Deposit

Company Name: Procel Temporary Services Inc. Company ID#: ______________

I hereby authorize the COMPANY, to make payments of any amount owing to me by initiating credit entries to
my account indicated in the bank names below, hereinafter called BANK, and I authorize and respect BANK to
accept any credit entries initiated by COMPANY to such account without responsibility for the correctness
thereof.

I also authorize and request COMPANY to effect repayments to COMPANY for any amounts owed it because of
prior erroneous credit initiated to my account if prior to initiation of the correcting entry, the COMPANY has
notified me of the correction and the reason therefore: and, the correcting entry is transmitted in such time as to
be delivered or make available to BANK before midnight of the tenth day next following for the erroneous entry.

It is understood that either party may terminate this agreement at any time by written notification to COMPANY
or BANK. Any such notifications to COMPANY shall be effected only with respect to entries initiated by
COMPANY after receipt of such notification and reasonable opportunity to act on it. Any such notification to
BANK shall be effective only with respect to entries credited into my account by BANK after receipt of such
notifications and reasonable time to act on it.

I recognize, acknowledge, and accept that this service is being provided for my convenience. As such, I agree to
hold the COMPANY, PROCEL, each participating bank and NACHA harmless from any claim incident to the
operating of this plan, arising from any act or omission by the COMPANY and/or PROCEL and their employees,
including without limitation any claim based on an alleged loss as a result of non-credit of any deposit, and any
claim which ay be made by any depositor as a result the rejection of any of his debits because of insufficient
funds arising from failure to credit deposits to my account.

Æ IMPORTANT!!!Å
ATTACH VOIDED CHECK FOR CHECKING ACCOUNT
OR
ATTACH DEPOSIT SLIP FOR SAVINGS ACCOUNT

Name of Institution: ______________________________________________________

Employee Name: _________________________________________________________

Account #: __________________________ Routing #: __________________________

Account Type: Checking † Savings † Cancel Direct Deposit †

Direct Deposit will be tested the first week. This is called a “Pre-Note”. The purpose is to ensure your
correct account. If test is successful the direct deposit will be activated the following week. Thereafter,
PROCEL will process direct deposit every payday (Thursday). Friday is usually the day our employees
receive their direct deposit pay. PROCEL cannot guarantee that your bank will post the direct deposit in
your account on Fridays. Therefore, please ask your bank representative when you can expect your money
to be deposited into your account.

I understand that is it my responsibility to notify PROCEL of any changes related to my direct deposit:
Bank, Account #, Closing, etc. I also understand that if I fail to notify PROCEL of these changes I may not
receive my direct deposit pay.

Name: __________________________________________________________________

Signature: ______________________________________ Date: ___________________


Revised 10/2008 LB

Documentation of the ability of patient’s and/or family to manage continuing care needs after discharge Evaluation of care by utilizing continuous performance improvement monitoring activities and patient outcomes Utilization of standards of patient care and standards of practice to provide patient care. Utilizations of resources such as the Code for Nurses, the patient Bill of Rights and other hospital established structures to guide ethical decision making. Provide care to patients and their significant others taking into consideration their cultural, religious, and social preferences as well as age specific care needs and incorporating these needs in the development and implementation of their plan of care. SPECIALTIES: Certain units require special training, skills and proven competency in addition to the usual skills of the Registered Nurse. These areas include, but are not limited to, the following: Intensive Care, Coronary Care Telemetry/DOU Emergency Department Operating Room PACU/Recovery Room Mental Health Obstetrics Neonatal Intensive Care Unit (NICU) Rehabilitation Post Partum Psychology Medical Surgical Pediatric Intensive Care Unit (PICU) Pediatrics

© PROCEL
PROCEL TEMPORARY SERVICES, INC.

Disclosure and Authorization to Obtain Investigative Consumer Report
In connection with my application for employment or promotion or other job change, I understand that Procel Temporary Services, Inc. (the Company) may obtain an INVESTIGATIVE CONSUMER REPORT that will include information as to my character, general reputation, personal characteristics and mode of living. This report may reveal information about work habits, including oral assessments of my job performance, experiences and abilities, along with reasons for termination of past employment. Such a report may be requested by the Company or on behalf of the Company. Further, I understand and agree that the Company may request information from various federal, state, and other agencies, including public and private sources which maintain records concerning my past activities relating to my driving record, credit history, criminal record, civil matters, previous employment, educational background and professional licensing, if any. Report may be ordered from:

Interstate Data/Megacriminal.com
Consumer Reporting Agency Name

113 Latigo Lane #401 Canyon City, CO 81212 (800)332-7999
Address City, State, Zip Telephone

and/or KROLL Background Check
Consumer Reporting Agency Name

600 Third Ave
Address

New York, NY 10016 (888)209-9526
City, State, Zip Telephone

and/or Insight Investigations, Inc.
Consumer Reporting Agency Name

PO Box 891571
Address

Temecula, CA 92589
City, State, Zip

(800)615-8111
Telephone

You have the right, upon written request made within a reasonable period of time (not to exceed 30 days) after receipt of this notice to receive a written disclosure of the nature and scope of any investigation. If a consumer investigative report is obtained and an adverse decision is made affecting your employment, the Company will provide to you, before making the adverse decision, a copy of the investigative consumer report and a description in writing of your rights under the Fair Credit Reporting Act.

You have a right to obtain a copy of any investigative consumer report obtained by Procel Temporary Services, Inc. by checking the box provided. The report will be provided to you within three business days after the report is provided to Procel Temporary Services, Inc.

I request to receive a free copy of this report by checking this box.

x

Under section 1786.22 of the California Civil Code, you may view the file maintained on your by the consumer reporting agency named above during normal business hours. You may also obtain a copy of this file upon submitting proper identification and paying the costs of duplication services, by appearing at the Consumer Reporting Agency identified above in person or by mail. You may also receive a summary of the file by telephone. The agency is required to have personnel available to explain your file to you and the agency must explain to you any coded information appearing in your file. If you appear in person, a person of your choice may accompany you, provided that this person furnishes proper identification.

Disclosure and Authorization to Obtain Investigative Consumer Report
I acknowledge that a fax or copy of this Disclosure and Authorization bearing my signature shall be valid as the original. This release is valid for all federal, state, county and local agencies and authorities. I acknowledge that I have received a copy of the Summary of Rights pursuant to the Fair Credit Reporting Act (FRCA).

Name

Address

City ( ) Home Telephone

State

Zip

Social Security Number

Date of Birth

Driver’s License #

State of Issue

Applicant Signature

Name: Date: _

_

Emergency Room

Skills Checklist

Using the scale(s) below, please complete the following skill self assessment based upon your experience within the last 2 years.
Proficiency: Frequency: [1] None [2] Intermittent [3] Experienced [4] Supervise/Teach [1] Never/Observed Only [2] Less than 6 times/year [3] Twice a Month [4] Daily - Weekly

Assessment/Patient Care Proficiency 1 2 3 4 General Admission Advance Directives Collect Appropriate Data Discharge Teaching Organ/Tissue Donation Patient and Family Teaching Suspected Abuse EMTALA Procedures Computerized Documentation Computerized Documentation Cardiovascular General Abnormal Heart Sounds/Murmurs Auscultation (Rate, Rhythm) Patient Experience Abdominal Aortic Aneurysm Acute Angina Acute C.H.F. Acute MI Cardiac Arrest/CPR Cardiac Tamponade Cardiomyopathy Defibrillation/Cardioversion Hypertension Myocardial Contusion Pacemaker -External Pacemaker -Permanent Monitoring

Frequency 1 2 3 4

Assessment/Patient Care Continued Proficiency 1 2 3 4 12 Lead EKG Interpretation Arrhythmia Interpretation Arterial Line CVP Monitoring Intra-Aortic Balloon Pump PA/Swan-Ganz Labs BNP (Brain Natriuretic Peptide) Cardiac Enzymes & Isoenzymes Coagulation Studies Troponin Pulmonary General Assess Lung Sounds Identify/Manage Resp. Complications Oxygenation Status Rate and Work of Breathing Patient Experience Acute Pneumonia ARDS Aspiration Chest Trauma Chest Tube COPD Hemopneumothorax Inhalation Injuries Near Drowning Pulmonary Edema Pulmonary Emboli Status Asthmaticus Tension Pneumothorax Tracheostomy Tuberculosis Monitoring Apnea

Frequency 1 2 3 4

DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD

DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD

DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD

DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD

DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD

Nationally Validated Content Copyright © 2010 Clearview Staffing Software Inc.

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I. please complete the following skill self assessment based upon your experience within the last 2 years.Weekly Assessment/Patient Care Continued Proficiency 1 2 3 4 Pulse Oximetry Lab Interpretation of ABGs Neurology General Glasgow Coma Scale Neurological Assessment Reflex/Motor Deficits Visual Communication Deficits Patient Experience Acute Head Injury Alzheimer's Disease Basal Skull Fracture Cerebral Hemorrhage/Aneurysm Closed Head Injury CNS Infection Coma CVA DTs Increased ICP Intracranial Hemorrhage Meningitis Neuromuscular Disease Seizure Disorder Spinal Cord Injury Halo Traction/Cervical Tongs Neurogenic Shock TIAs Monitoring ICP Monitoring Gastrointestinal General Frequency 1 2 3 4 DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD Assessment/Patient Care Continued Proficiency 1 2 3 4 Assess Nutritional Status G. Assessment Patient Experience Abdominal Trauma Abdominal Wounds and Surgeries Acute GI Bleed Bowel Obstruction Esophageal Bleed Hepatitis Ileostomy Liver Failure Pancreatitis Paralytic Ileus Poison Ingestion Labs LFTs (Liver Function Test) Serum Ammonia Serum Amylase Renal/Genitourinary General Assess Fluid Status Patient Experience Acute Renal Failure End Stage Renal Disease Peritoneal Dialysis Renal Rejection Syndrome Renal Transplant Suprapubic Cath Urinary Tract Infection Fistula/Shunt Monitoring Fluid Balance Measurement of I & O Labs BUN & Creatinine Frequency 1 2 3 4 DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD Nationally Validated Content Copyright © 2010 Clearview Staffing Software Inc. Page 2 of 6 . Proficiency: Frequency: [1] None [2] Intermittent [3] Experienced [4] Supervise/Teach [1] Never/Observed Only [2] Less than 6 times/year [3] Twice a Month [4] Daily .Name: Date: _ _ Emergency Room Skills Checklist Using the scale(s) below.

Proficiency: Frequency: [1] None [2] Intermittent [3] Experienced [4] Supervise/Teach [1] Never/Observed Only [2] Less than 6 times/year [3] Twice a Month [4] Daily . please complete the following skill self assessment based upon your experience within the last 2 years.Name: Date: _ _ Emergency Room Skills Checklist Using the scale(s) below. Page 3 of 6 .Weekly Assessment/Patient Care Continued Proficiency 1 2 3 4 Serum Electrolytes Endocrine/Metabolic Patient Experience Adrenal Gland Disorders Diabetic Ketoacidosis Drug Overdose Insulin Shock Pituitary Gland Disorders Diabetic Coma Insulin Reaction Thyroid Gland Disorders Labs Blood Glucose Thyroid Studies Musculoskeletal General Pulse/Circulation Checks Patient Experience Amputation External Fixation Multiple Trauma Paraplegia Skeletal/Skin Traction Cast Care Fractures Crutch Walking Immunology/Hematology/Oncology General Blood Transfusions Patient Experience Acute Leukemia Anaphylactic Shock Cancer HIV/AIDS Frequency 1 2 3 4 Assessment/Patient Care Continued Proficiency 1 2 3 4 Sepsis Sickle Cell Anemia Treatment Side Effects Chemo/Radiation Labs Hematology Wounds/Integument General S/S Infection Skin Assessment Patient Experience Burns Hazardous Material Exposure Pressure Sores Shingles Staged Decubitus Ulcers Stasis Ulcers Surgical Wounds Surgical Wounds w/Drains Traumatic Wounds Monitoring Skin Breakdown Women's Health General Abruptio Placenta DIC Eclampsia Hemorrhage Precipitous Delivery Preeclampsia Premature Labor Rape Kit Spontaneous Abortion Medications/Therapeutic Interventions I General Adenocard Frequency 1 2 3 4 DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD I Nationally Validated Content Copyright © 2010 Clearview Staffing Software Inc.

Proficiency: Frequency: [1] None [2] Intermittent [3] Experienced [4] Supervise/Teach [1] Never/Observed Only [2] Less than 6 times/year [3] Twice a Month [4] Daily . Date: _ _ Emergency Room Skills Checklist Using the scale(s) below.Name:.Weekly Medications/Therapeutic Interventions Continued Proficiency Frequency 1 2 3 4 1 2 3 4 Adrenalin Antiemetics Antispasmodic Atropine Bicarbonate Bretylium (Bretylol) Bumex Cardizem (Diltazem) Charcoal Decadron Dilantin Dobutamine Dopamine Epinephrine Esmolol Heparin Insulin Ipecac Isuprel Lanoxin Lasix Lidocaine Mannitol Nipride (Nitroprusside) Nitroglycerin Nitroprusside Paralytics Phenobarbital Pitressin Pronestyl (Procainamide) Retavase Solu-Medrol Steroids Streptokinase Tenectaplase (TNKase) Terbutaline TPA/Thrombolytics Verapamil Versed Theophylline DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD Medications/Therapeutic Interventions Continued Proficiency Frequency 1 2 3 4 1 2 3 4 Medications Administration Administer IM and SQ Meds Administer Inhalation Medications Administer PO Medications Bladder Irrigation and Instillation Ear Irrigation Eye Irrigation Needleless Systems IV Therapy Adverse Reactions Assess/Maintain IV Site CVP Lines/Measurement of CVP Infusion Pumps Peripheral IV Insertion Syringe Pumps Vascular Access Devices Care/Maintenance Administer IV Medications Mixing IV Solutions Blood Administer Blood/Blood Products Albumin Nutritional Therapy NGT Insertion TPN and Hyperalimentation Oxygen Administration Ambu-Bag Nasal Cannula DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD Nationally Validated Content Copyright © 2010 Clearview Staffing Software Inc. Page 4 of 6 . please complete the following skill self assessment based upon your experience within the last 2 years.

Name: Date: _ _ Emergency Room Skills Checklist Using the scale(s) below. Page 5 of 6 . Female Foley. PEEP) Pain Management Assess Pain Level/Tolerance Moderate Sedation Ramsey Scale Procedures/Equipment Perform Applying Brace/Splint Cast Cervical Collar Chest Tube Drainage Systems Crisis Intervention Doppler Drains (JP-Hemovac-Penrose) Dressing Changes Establish/Protect Airway Foley. 3-Way Foley. Proficiency: Frequency: [1] None [2] Intermittent [3] Experienced [4] Supervise/Teach [1] Never/Observed Only [2] Less than 6 times/year [3] Twice a Month [4] Daily . please complete the following skill self assessment based upon your experience within the last 2 years.Weekly Medications/Therapeutic Interventions Continued Proficiency Frequency 1 2 3 4 1 2 3 4 Nebulizer Treatments Non-Rebreather Mask Portable Oxygen Tracheostomy Venti Mask Ventilator (A/C. Male Hyper/Hypothermia Blanket Iced Saline Lavage Isolation Pinned Fractures Restraints Steristrips Suctioning (Oral-Naso-Pharynx) Suicide Precautions Trach Care/Suctioning Wound Care/Irrigations Wrist Splint DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD Procedures/Equipment Continued Proficiency 1 2 3 4 Specimen Collections Arterial Line Draw Assist with Rape Exam Butterfly Stick Central Line Draw Clean Catch Urine Cultures-Blood Dipstick Urine Finger Stick Stool Sputum Sterile Urine Throat Swabs Venipuncture Assist Arterial Line Insertion Bedside Invasive Procedures Bronchoscopy Cardioversion/Defibrillation Central Line Insertion Chest Tube Insertion Emergency Tracheostomy ET Intubation and Extubation Halo Traction/Cervical Tongs Placement IV Cutdown Lumbar Puncture Nasal Packing Open Chest Emergency PA Catheter/Swan-Ganz Insertion Pericardiocentesis Pericentesis Staples Assist/Removal Sutures Assist/Removal Frequency 1 2 3 4 DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD DDDD I Nationally Validated Content Copyright © 2010 Clearview Staffing Software Inc. IMV.

39 Years 39 .64 Years 64+ Years Trauma Level Experience Level I Level II Level III Clinical Settings Acute Care ER Chest Pain ER CHF Clinic Flight Nursing Pacemaker Clinic Urgent Care Clinic Ambulance/Transport DODD DODD DODD DODD DODD DODD DODD DODD DODD DODD DODD DODD DODD DODD DODD DODD DODD DODD DODD DODD páÖå~íìêÉ= Nationally Validated Content Copyright © 2010 Clearview Staffing Software Inc.5 Years 5 .12 Years 12 .18 Years 18 .Name: Date: _ _ Emergency Room Skills Checklist Using the scale(s) below.1 Year 1 . Proficiency: Frequency: [1] None [2] Intermittent [3] Experienced [4] Supervise/Teach [1] Never/Observed Only [2] Less than 6 times/year [3] Twice a Month [4] Daily .3 Years 3 . a~íÉ Date Page 6 of 6 . please complete the following skill self assessment based upon your experience within the last 2 years.Weekly Procedures/Equipment Continued Proficiency 1 2 3 4 Thoracentesis Insert Temp-Pacemaker Frequency 1 2 3 4 DODD DODD DODD DODD DODD DODD DODD DODD DODD DODD DODD DODD DODD DODD DODD DODD DODD DODD DODD DODD DODD DODD I Age Group Experience Age Groups 0 .30 Days 30 Days .

A clear understanding of your background and work history will aid us in placing you in a position that is best suited for you.TO APPLICANTS: We deeply appreciate your interest in our organization and assure you that we are sincerely interested in your qualifications. Licensure/Credentials: State: State License: _____________________ _____________________ Foreign: _____________________ Education Preparation: Name/Address: High School: ______________________ ______________________ College: ______________________ ______________________ Year Graduated: (Mo)_______(Yr)________ _______________________ (Mo)_______(Yr)________ _______________________ Degree(s) Obtained: _____________________________ _____________________________ _____________________________ _____________________________ License Number: # _____________________ # _____________________ # _____________________ Expiration Date: (Mo) _________ (Yr) __________ (Mo) _________ (Yr) __________ Date Obtained: ________________ 3. Application Form "Gold Seal of Approval" 1. PERSONAL: Name: _________________________________________________________________________________________ (Last) (First) (Middle) Address: (Current) _______________________________________________________________________________ (Number) (Street) (Apt/Unit/Suite #) ________________________________________________________________________________________ (City) (State) (Zip/Postal Code) Permanent Address: _________________________________________________________________________________ (If different from above) (Number/Street/Apt) (City/State) (Zip) Telephone Number(s): Home/Day: (____) _______-____________ Cell/Pager: (____) _______-____________ In Case of Emergency. Continuing Education for the last two (2) years: Completion Date _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ Provider Number _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ Course Name Contact Hours _________________________________ __________ _________________________________ __________ _________________________________ __________ _________________________________ __________ _________________________________ __________ _________________________________ __________ _________________________________ __________ _________________________________ __________ . Contact: Name: _____________________ Number: (____) _______-____________ E-Mail Address: ____________________________________________________________________________ INTERESTED IN: x PER DIEM x TRAVEL 2.

Work Experience: (Please provide last seven (7) years work history. please indicate how many months/years you have worked in each unit at this facility: Unit: __________ Years of Experience: ___________ Unit: __________ Years of Experience: ___________ Unit: __________ Years of Experience: ___________ Unit: __________ Years of Experience: ___________ Duties and Responsibilities: __________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 2) Name and Address of Employer: Employer: City. State: Employment Dates .From: _____(mo) _______ (yr) To: _____(mo) _______ (yr) Main Phone #: Facility Name: Indicate Specific Unit(s): Was this a Travel Assignment? x No x Yes Job Title: If you have experience in more than one unit. Most recent or current employer first) 1) Name and Address of Employer: Employer: City. please indicate how many months/years you have worked in each unit at this facility: Unit: __________ Years of Experience: ___________ Unit: __________ Years of Experience: ___________ Unit: __________ Years of Experience: ___________ Unit: __________ Years of Experience: ___________ Duties and Responsibilities: __________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ .4.From: _____(mo) _______ (yr) To: _____(mo) _______ (yr) Main Phone #: Facility Name: Indicate Specific Unit(s): Was this a Travel Assignment? x No x Yes Job Title: If you have experience in more than one unit. State: Employment Dates . please indicate how many months/years you have worked in each unit at this facility: Unit: __________ Years of Experience: ___________ Unit: __________ Years of Experience: ___________ Unit: __________ Years of Experience: ___________ Unit: __________ Years of Experience: ___________ Duties and Responsibilities: __________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 3) Name and Address of Employer: Employer: City. State: Was this a Travel Assignment? x No x Yes Job Title: Facility Name: Indicate Specific Unit(s): Employment Dates .From: _____(mo) _______ (yr) To: _____(mo) _______ (yr) Main Phone #: If you have experience in more than one unit.

State: Was this a Travel Assignment? x No x Yes Job Title: Facility Name: Indicate Specific Unit(s): Employment Dates .From: _____(mo) _______ (yr) To: _____(mo) _______ (yr) Main Phone #: Facility Name: Indicate Specific Unit(s): Was this a Travel Assignment? x No x Yes Job Title: If you have experience in more than one unit. State: Employment Dates .4. Work Experience: (continued) 4) Name and Address of Employer: Employer: City. please indicate how many months/years you have worked in each unit at this facility: Unit: __________ Years of Experience: ___________ Unit: __________ Years of Experience: ___________ Unit: __________ Years of Experience: ___________ Unit: __________ Years of Experience: ___________ Duties and Responsibilities: __________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 6) Name and Address of Employer: Employer: City.From: _____(mo) _______ (yr) To: _____(mo) _______ (yr) Main Phone #: Facility Name: Indicate Specific Unit(s): Was this a Travel Assignment? x No x Yes Job Title: If you have experience in more than one unit. State: Employment Dates .From: _____(mo) _______ (yr) To: _____(mo) _______ (yr) Main Phone #: If you have experience in more than one unit. please indicate how many months/years you have worked in each unit at this facility: Unit: __________ Years of Experience: ___________ Unit: __________ Years of Experience: ___________ Unit: __________ Years of Experience: ___________ Unit: __________ Years of Experience: ___________ Duties and Responsibilities: __________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ . please indicate how many months/years you have worked in each unit at this facility: Unit: __________ Years of Experience: ___________ Unit: __________ Years of Experience: ___________ Unit: __________ Years of Experience: ___________ Unit: __________ Years of Experience: ___________ Duties and Responsibilities: __________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 5) Name and Address of Employer: Employer: City.

I have a MINIMUM OF ONE-YEAR experience in the following units and I am prepared to care for patients in these specialties: x General Medical/Surgical x Hospice Care x Telemetry x Stepdown x Intensive Care/ICU x PACU x Operating Room x Emergency Room x Outpatient Clinic x Cath Lab/Cardiology x Pre-Op Holding x Post-Op Care x GI-LAB x PICU x NICU x Labor & Delivery x PEDS C/V x PEDS General x PEDS Oncology x Nursery II x Nursery N/B x Couplet Care x Surgery Center x Psychiatric General x Chemical Dependency x Adolescent Psychiatric 7. _________________________________ ___________________ ___________________ ______________________ 6.com x Internet/Web x Career Builder x Hospital Referral x Nurse Referral Name: First ______________ Last ______________ Phone Number: _____________________ and/or Email: __________________________ x Other: __________________________________________________________ 8. (Reminder to applicants: We do Criminal Background Screening on ALL applicants before hire) Do you drive? x YES x NO x YES x NO Do you have a car or other transportation for work? What languages other than English do you speak/write and understand? _________________________________________________________________________________________ . _________________________________ ___________________ ___________________ ______________________ 2. Have you ever been convicted of any crime? If so. _________________________________ ___________________ ___________________ ______________________ 4. WHEN? x YES x NO Date: _____________________ Place: __________________________________________________ An Affirmative Response is not an automatic bar from employment. _________________________________ ___________________ ___________________ ______________________ 3.5. Referral Source: x Walk In x Nurseweek x Nurse Magazines x Healthcare Traveler Journal x Monster. Work References: Manager/Charge Nurse Name Facility Position Contact Number 1.

and all other persons. color. and for any reason or no reason. reports and other information related to my work records. or liabilities arising. corporations. I understand that any omission or misstatement of material fact on this application or any documentation used to secure employment shall be ground for rejection of this application. regardless of the time elapsed before discovery. physical handicap or medical condition in accordance with the Federal and State Equal Opportunity Laws. I understand and agree that if I am employed. (Procel) to thoroughly investigate my references. partnerships and associations from any and all claims. have personally completed this application. and other matters related to my suitability for employment. or in any way related to. I further understand that Procel complies with all applicable Accreditation of Healthcare Organizations (Joint Commission) and with regulations related to HIPAA Security Compliance. age. and to refer all qualified candidates. I understand that nothing contained in the application or conveyed during any interview that may be granted is intended to create an employment contact between Procel and myself. education. our of. such investigation or disclosure. I understand it is the Policy of Procel to comply with the Drug-Free Workplace Act of 1988. Inc. without regard to race. In addition. demands. In addition. at the option of either myself or Procel and that promises or representations contrary to the forgoing or given at any time in the future are not binding. or that may arise. national origin. I hereby authorize Procel Temporary Services.Employment Agreement I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further authorize my former employers to disclose Procel all letters. sex. work record. my employment is At Will and is for no definite or determinable period and may be terminated at any time. I hereby release Procel my former employers. or for immediate discharge if I am employed. without giving me prior notice of such disclosure. Applicant Name (PLEASE PRINT) Date Applicant Signature Revised: 03/11/11 . with or without prior notice. I hereby certify that I. the undersigned applicant.

Furthermore. who tests positive in a confirmed drug test. Employees shall not report to work with illegal substances in their systems. lost profits. distributing. up to and including termination. VI. IV. . will not be returned to work until they have been evaluated by the Company’s coordinating physician (MRO) in conjunction with the management to determine if they can safely return to work. V. alcohol abuse. Employees who are not immediately terminated for testing positive or for some other violation of the policy may at the sole discrete of the Company. and legal difficulties for employees and employers. admit to drug and alcohol use or distribution. recognizes the legal and moral responsibility to provide a safe and productive work environment for all employees. a written release of the results of that test will be obtained from the employee or applicant being testes. cultivating. injuries. INC. or who has successfully completed a drug or alcohol drug rehabilitation program as a condition of continued employment to sign an agreement which will include periodic random testing for a specific period of time following his or her reentry. will be reviewed by the MRO and depending upon that report will be subject to discipline up to and including termination. Statistics show that drug and alcohol use in the workplace results in accidents. Laboratory reports test results shall appear in an employee’s personnel folder in a secured location (envelope). increased health care costs. APPLICANTS FOR EMPLOYMENT All applicants will be informed that as a part of an offer of employment. safety and well being of our employees. Prior to administering any drug test. PRESCRIPTION DRUGS The use of prescription drugs. without the prior approval of the CEO. we have adopted this policy that all employees must repot to work completely free fro the presence of illegal drugs and the effects of alcohol. the applicant will be required to undergo a drug test. Applicants who test positive will be reviewed by the Medical Review Officer and depending on that report a decision to hire will be made. ILLEGAL DRUG USE AND DISTRIBUTION All employees are prohibited from manufacturing. dispensing. Clearly the use. Applicants who decline to undergo the drug test will not be considered for employment. as part of a prescribed medical treatment by a licensed physician is not prohibited. possession or sale of illegal drugs and alcohol in the workplace poses serious risks to the health. REHABILITATION MONITORING An employee who tests positive in a confirmed drug test. from the Company premises. III. possessing or using illegal or other mind-altering or intoxicating substances while on Company premises (including parking areas and other Company grounds).DRUG AND ALCOHOL POLICY I. DRUG TESTING Employee’s who test positive. POSITIVE TEST RESULTS Any employee. and who are not terminated. or while otherwise performing duties away. For these reasons. In the selected circumstances when alcohol use has been permitted. The release of drug test results is strictly forbidden without the specific consent of the applicant or employee authorizing release of his or her information. Results and record of drug tests are confidential and handled on a need-to-know basis. II. lower productivity. be suspended without pay pending a review of an MRO (medical review officer) or other responsible corporate officer. It is in the employee’s responsibility to determine whether a prescribed drug may impair job performance. unruly or unbusiness like behavior will not be tolerated and may result in discipline. STATEMENT OF PURPOSE OF POLICY PROCEL TEMPORARY SERVICES. An employee is required to inform his or her supervisor if the legal use of a prescription drug will in any way affect the ability to safely perform his or her assigned job. ALCOHOL AND USE IMPAIRMENT All employees are prohibited from using alcohol on Company property on while on Company related business. all employees are prohibited fro having alcohol in their systems while at work or on duty.

Nothing in this section shall be constructed to prohibit the Company from imposing discipline for violations of other work rules or misconduct committed by an employee who voluntarily enters an Employee Assistance Program. it is the responsibility of the employee to seek and accept assistance before drug and alcohol problems lead to disciplinary action. DISCIPLINARY ACTIONS Violations of this policy will result in disciplinary action. Employees will be expected to cooperate in the conduct of such inspections as a condition of continued employment. management retains the right to inspect all personal and company property. the Company may do so for him or her and compensate the employee for the lock. X. which is or may be a part of the policy violation. INSPECTIONS AND TESTING Where the Company has reasonable suspicion that an employee has violated the drug and alcohol policy. IX. to promptly report that fact to their immediate supervisor. Many facilities require a drug screen 30 days prior to starting a travel assignment. I understand that it is my responsibility to read and comprehend its on contents and should I have any questions. XII. Where the employee is not present or refuses to remove a personal lock. NOTIFICATION OF IMPAIRMENT It shall be the responsibility of each employee who observe or has knowledge of another employee in a condition which impairs the employee’s ability to perform their job duties. SEARCHES. including termination. or is otherwise in violation of this policy. Strict confidentiality of records and information will be maintained. I have the right to terminate my employment with or without cause at any time and I understand that the Company has a similar right. It represents PROCEL’s current standards for dealing with a serious national problem and is subject to change. purses and briefcases. Refusal will result in termination. The Company may refer such illegal drug activities to law enforcement agencies. purchase. I will contact my supervisor. Failure to enter. Employment may be terminated even for a first time violation. the Nurse/Tech will be asked to take a drug screen. Should a facility have reason to believe that a Nurse/Tech has a substance abuse problem. __________________________________________________________________ First Name Last Name ___________________________________________________________________ Employee Signature Date This policy should not be considered as a contractual in nature. Nothing in this policy alters my status as an “at will” employee. However. ACKNOWLEDGEMENT OF UNDERSTANDING I acknowledge receipt of the Company’s Drug and Alcohol Abuse Policy. desks.VII. Disciplinary action may include suspension and/or immediate termination of employment. or who presents a hazard to the safety of others. sale. XI. transfer or possession of an illegal drug is usually a violation of law. . VIII. remain or successfully complete a prescribed treatment program may result in termination of employment. INVOLVEMENT OF LAW ENFORCEMENT AGENCIES The use. The Company will help employees who abuse alcohol or drugs by providing a referral to an appropriate professional organization. The right to inspect will include but not limited to vehicles (both personal – while on company property – and company owned). EMPLOYEE ASSISTANCE The Company expects employees who suspect they have an alcohol or drug problem to seek treatment.

REFERENCE CHECK FORM APPLICANT INFORMATION Name: Employed: From: To: Specialty: Classification: REFERENCE INFORMATION Name: Phone: Facility: Address: City: State: Zip: Title: Unit: EVALUATION Personal Evaluation Attendance Punctuality Quality of Work Performance Skill Attitude Initiative Adaptability Appearance Co-Operation Would you rehire this employee? ________ Yes _________ No Excellent Good Fair Poor Comments: .

6. 7. sores or abscesses Diarrhea lasting more than 48 hours with blood/mucous in stool YES YES YES YES YES YES NO NO NO NO NO NO If you have a positive PPD. 2. a baseline chest x-ray is required every 4 years. I hereby give my consent for the appropriate tests to be done as indicated. year: ______) Have you ever taken any medication for TB? In the past 12 months. __________________________________________________________________ First Name Employee Signature Last Name Date __________________________________________________________________ JCAHO CERTIFIED 2447 Pacific Coast Highway Suite #207 Hermosa Beach.PROCEL TUBERCULOSIS SCREENING QUESTIONNAIRE Please answer YES or NO to the following: 1. 5. Date of last chest x-ray: ______________________ Results: _________________________ PPD POSITIVE DATE: ____________________ INDURATION: __________________ I understand that all employees must have an annual Tuberculosis Screening. CA 90254 Phone: 310-372-0560 Fax: 310-372-6067 www. have you had any of the following: YES YES YES YES YES NO NO NO NO NO Persistent Cough Night Sweats Excessive Fatigue Persistent skin rashes.procelnurses. Have you ever been diagnosed with Tuberculosis (TB)? Have you ever had a positive or reactive TB test? Have you had a TB immunization in the past 6 months? Are you taking corticosteriods or immunosuppressive meds? Have you ever had a BCG vaccination? (If yes. 3.com . 4.

__________________________________________________ First Name Last Name __________________________________________________ Signature Date .LATEX ALLERGY QUESTIONNAIRE I DO have a latex allergy I DO NOT have a latex allergy I DO have a SENSITIVITY TO POWDER and require powder free gloves My signature below indicates that the above information is correct and I give permission for this information to be shared with PROCEL for the purpose of staffing placement with contracting facilities.

Hand hygiene is the use of soap and water or alcohol gel. as mandated by federal or state regulation or standard Catergory II: Suggested for implementation and supported by suggestive clinical or epidmiologic studies or a theoretical rationale. STANDARD PRECAUTIONS Standard precautions are based upon common sense.which are to be followed with every patient. and any item that is glued or pierced through the nail. Patients in Isolation have a sign on or near the door telling you what is required before entering the room. _____________________________________________________________ First Name Last Name _____________________________________________________________ Signature Date . * Natural nails: nails without artificial covering other than fresh nail polish. extenders. Catergory IB: Strongly recommended for implementation and supported by certain experimental clinical or epidemiologic studies and a strong theoretical rationale. acrylics. including wraps. Recommended Practices. * Wash hands before/after patient care to prevent carrying organisms from one patient to another. gels. each recommendation is categorized on the basis of exisisting scientific data. Always use gloves when carrying patients with diarrhea & use soap & water (not alcohol rub) after removing gloves. I. The CDC/HICPAC system for catergorizing recommendations is as follows: Catergory IA: Strongly recommended for implementation and strongly supported by well-designed experimental. Catergory IC: Required for implementation. Practices for which insufficient evidence or no consensus regarding efficacy exsist. Recommended Practices. They apply to the care of all patients. HAND HYGIENE It may seem basic. theoretical rationale. 2002 Standards. This means that you hands must be in contact with soap and water for a full 15 seconds. tips.followed only for patients with certain diseases or organisms. yet inadequate hand hygiene is one of the most common reasons that patients get infections. every time * Isolation Precautions . simple. * Fresh Nail Polish: nail polish that is not obviously chipped or worn for more than four days (AORN. since it's not always possible to tell who is infectious. The very basics of standard precautions include hand hygiene. * Alcohol gel does not kill C difficile spores which cause AB associated diarrhea. Hand Hygiene is the single most important infection control activity in a Hospital.Hand Hygiene There are two basic sets of Infection Control procedures: * Standard Precautions . (AORN. and economic impact. and Guidelines). Hand Hygiene Recommendations from CDC CATERGORIES These recommendations are designed to improve hand-hygiene practices of health care workers and to reduce transmission of pathogenic microorganisms to patients and personnel in health-care settings. Find a clock with a second hand now and note how long 15 seconds is… its longer than you think! See below. As in previous CDC/HICPAC guidelines. * Artificial Nails are not allowed in ANY Health Care Facility. applicability. and Guidelines). No recommendation: Unresolved issue. * Use of alcohol gel on non-visibly soiled hands is now recommended as a substitute for hand washing Its effective and good for hands. Any material applied or added to the natural nails to augment or enhance (strenghten and lenghten) the wearer's own fingernails. clinical or epidemiologic studies. overlays. 2002 Standards. easy to do.

to provide my personnel and medical information to Facilities currently Contracted with Procel. Unless otherwise stated or mandated by law. The use of the information supplied is to be restricted to the foregoing stated verification. the undersigned. Release or transfer of the specified information to any person or entity not specified herein is prohibited. ___________________________________________________ First Name Last Name ___________________________________________________ Signature Date NOTICE TO EMPLOYEE You have a right to receive a copy of this authorization. An additional written consent must be obtained for a proposed new use of the information or for its transfer to another or entity. . hereby authorize Procel Temporary Services Inc. for the purpose of verifying that I meet the requirements specified in the Agreement For Temporary Staffing of Nursing Services. this release of information consent form will not expire.AUTHORIZATION OF RELEASE OF PERSONNEL AND MEDICAL INFORMATION I.

I can receive the vaccination series at no charge to me. a serious disease. I decline the Hepatitis B vaccine at this time. I understand that by declining the vaccine. I may be at risk of acquiring Hepatitis B (HBV) infection. I have been given the opportunity to be vaccinated with the Hepatitis B vaccine. I continue to have occupational exposure to blood and or other potentially infectious materials and I want to be vaccinated with Hepatitis B vaccine.HEPATITIS B VACCINATION DECLINATION I understand that due to my occupational exposure to blood and/or other potentially infectious materials. I continue to be at risk of acquiring Hepatitis B. in the future. __________________________________________ Name __________________________________________ Signature Date Revised: 6/30/2010 . If. However.

I ACKNOWLEDGE THAT I AM AWARE OF THE FOLLOWING FACTS: • • • • Influenza is a serious respiratory disease that kills. 36. I CHOOSE TO DECLINE VACCINATION AT THIS TIME. □ I HAVE HAD THE VACCINATION. If you have had the vaccination please provide proof of the vaccination. In California. I may change my mind and accept vaccination later. I have declined to receive the influenza vaccine for the 2008-2009 season. influenza usually arrives around New Year through February or March. making annual vaccination necessary.000 Americans every year. allowing transmission to others. • Please check one of the boxes below: □ KNOWING THESE FACTS. however. if vaccine is available. Up to 30% of people with influenza have no symptoms. It does not. on average. allowing transmission to others. ________________________________________________________________________ First Name Last Name ______________ Date Signature . including death. Influenza virus may be shed for up to 48 hours before symptoms begin. prevent all disease. to patients. I acknowledge that influenza vaccination is recommended by the CDC for all healthcare workers to prevent infection from and transmission of influenza and its complications.INFLUENZA VACCINE DECLINATION Written declination is required by new California Law (SB 739) beginning 2007. my family and my community. Flu virus changes often. Immunity following vaccination is strongest for two (2) to six (6) months. my coworkers. I understand that flu vaccine cannot transmit influenza. I have read and fully understand the information on this declination form.

I can still receive the Tdap vaccination at my OWN expense. and 2) the potential risk and benefits of the Tetanus. I will continue to be at risk of acquiring a serious disease. I understand that by declining the Tdap vaccine. I have elected NOT to receive the Tdap vaccine at this time. Diphtheria and Pertussis (Tdap) vaccine. _____________________________________________________________________ Name (Please Print) _____________________________________________________________________ Signature Date Revised: 12/07/10 . I understand I may be at risk of acquiring Pertussis due to my occupational exposure to aerosol transmissible diseases. I decline the Tdap vaccination at this time. If in the future I want to be vaccinated. I have been given the opportunity to be vaccinated against this disease or pathogen at my OWN expense but.Tdap Declination: I have read and have had an opportunity to review the latest CDC educational material (Vaccine Information Sheet Tdap) and ask questions regarding: 1) Tetanus. Diphtheria and Pertussis and their risks to healthcare personnel. I understand that I may elect to receive the Tdap vaccine at a later time.

Index: 1 2 3 4 5 6 7 8 Page Numbers: Qualifications of Procel Temporary Services. 6-8 9-11 Patient Rights …………………………………………………………………… HIPAA Privacy Act and Confidentiality Management ………………………… 12-13 Infection Control: Hand Hygiene and OSHA Regulations ………………………… 14-18 Standard Precautions a Hand Hygiene (CDC Guildelines) b Exposure to blood products c OSHA's Exposure Control plans -Bloodbourne Pathogens -Hepatitis B Virus -Tuberculosis Safety in the Environment of Care ………………………………………………………. 1 2 Cultural Diversity …………………………………………………………………… Continuous Quality Improvement …………. Job Description Registered Nurse ……………………………………… 64-65 Procel Temporary Services...…………………………………………… 3 4-5 Patient Safety 2009 …………………………………………………………………… Joint Commission National Patient Safety Goals ……. and Mission Statement …………. 39-42 43-46 Age Specific Related Care ………………………………………………………………… Pain Assessment and Management …………………………………………………. LVN's. Capping and Organ Donation …………………………………… 49-50 51-56 Suspected Abuse …………………………………………………………………… a Suspected Child Abuse and Neglect b Suspected Abuse of Elders and Dependent Adults c Domestic Violence Abbreviations: Joint Commission Official "Do Not Use" List ………………………… 57 9 10 11 12 13 14 15 16 Employee Handbook 1 2 3 58 Team Dynamics …………………………………………………………………… Corporate Compliance and Reporting to the Joint Commission ……………………….procelnurses. From the website go to Employee Forms and select the Orientation Manual document.. Inc. 59-62 Terms of Employment and Job Descriptions ……………………………………… 53 a.………………………………. TECH's. 47-48 Advance Directives. Social Workers and CNA's Our orientation manual can be viewed by CD or on our website at www.com. .. Inc. 19-35 a General Safety b Fire and Life Safety c Hospital Emergency Preparedness d Electrical and Medical Equipment Safety e Patient Fall Prevention f Utility System Safety g Hazardous Materials and Material Safety Data Sheets (MSDS) h Radiation Safety i Safety and Violence in the Workplace j Medications Safety 36-38 Body Mechanics …………………………………………………………………… Restraints and Seclusion ………………………………………………………………….poration heslthcsl"8 staffing BElrW:e Orientation and Annual Educational Updates RN's. RT's.

Inc. ……………………………………… 79 80 Workers Compensation Benefits ………. Job Description Respiratory Therapist ……………………………………… 72-73 h. I have been given the opportunity to seek clarification on any information that I may have had questions.…………………………………………… Harassment Prevention Policy ………..Orientation Index Continued: b.…………………………………………… 78 Floating Policy …………………………………………………………………… Dress Code and Hand Hygiene Policy. Job Description Licensed Vocational Nurse ……………………………………… 67-68 d. Job Description Medical Social Worker ……………………………………… 76 77 Per Diem Policies and Procedures ……….. Job Description Instrument Technician ……………………………………… 71 g. Job Description Operating Room Technician ……………………………………… 70 f..…………………………………………… 85 4 5 6 7 8 9 10 I have thoroughly and completely read and understand the Orientation and/or Annual Education provided. Job Description Certified Nursing Assistant ……………………………………… 69 e. etc.…………………………………………… 84 Community Emergency Prevention ………. Job Description Registered Nurse/Operating Room ………………………… 66 c. I understand a copy of this acknowledgement will be placed in my file.…………………………………………… 81-83 Personnel Counseling Policy ………. Job Description Case Manager …………………………………………………… 74-75 i. .. __________________________________________________ First Name Last Name __________________________________________________ Employee Signature __________________ Date Procel Temporary Services..

•PROCEL is dedicated to providing Facilities with Nurses and Technicians who demonstrate compassionate and safe patient centered care.org I have reviewed the PROCEL Code of Ethics and I know how to contact Joint Commission. feels and situations. which they are currently unable to deal with independently. confidentiality and mutual respect. •PROCEL recognizes and supports the Patient Bill of Rights. State and Federal. •PROCEL participates in comprehensive Quality Improvement Program that addresses Operations. •PROCEL believes in providing prompt and courteous service to all Nurses. _____________________________________________________________ First Name Last Name ______________________________________________________________ Employee Signature Date . •PROCEL facilitates clear and continuous communication with Staff Nurses. EEOC. Practice. JCAHO. •PROCEL supports and encourages partnerships with Client Facilities and Nurses through teamwork and collaboration. Technicians and Client Facilities. Anyone believing that he or she has pertinent and valid information about such matters related to patient quality and patient safety issues may provide input to the Joint Commission by submitting a complaint to the Office of Quality Monitoring at: Division of Accreditation Operations Office of Quality Monitoring Joint Commission on Accreditation of Healthcare Organizations One Renaissance Boulevard Oakbrook Terrace. OSHA. IL 60181 Faxed to (630) 792-5636 or E-mailed to compliant@jcaho.CODE OF BUSINESS ETHICS PROCEL Daily Mission: Is to earn our customers business for life by exceeding their expectations and delighting them with our service. Joint Commission standards relate to quality and safety of care issues. •PROCEL provides PROfessionals who exCEL in their clinical practice and who make a difference in how care is delivered to patients in all Clinical settings. •PROCEL values honesty. •PROCEL believes patients are individuals who have needs arising from conditions. •PROCEL Corporal Employees have the responsibilities to insure through a clinical screening process. •PROCEL strives to achieve the highest standard of clinical practice and an excellent reputation amongst Healthcare Facilities. •PROCEL believes in an environment that promotes practice and productivity. encourages excellence and provides for growth. •PROCEL contributes to the success of our Clients and Nurses through active Partnership and through commitment to the success of our Organization. Technicians and Facility Staff. and Safe Patient Care. that all Nurses and Technicians have met Procel’s hiring standards. •PROCEL is dedicated to full compliance with Regulations Agencies.

the learner wil be able the learner will be able to: 1. PROCEL Nurses committed caring PROCEL Nurses is committed to caring for patients all the days of their patients the days their lives. That excellent culturally competent life care is That excellent culturally competent end of life care is the physical. spiritual and emotional 1. Part of the care includes end of life care. 2. not the last days. right along with education about their disease process. our nurses years and months of life and to meet this need. After reading this section on Needs of Dying Patients and End of Life Care. believe: We believe: 1. Discuss the need toto meet physical. That and symptom management every patient's That pain and symptom management is every patient's right along education about their disease process. spiritual and emotional needs patient. 3. patient. lives. 2. physically. needs of the dying patient. Discuss the need meet physical. That it is our responsibility to meet the needs of . the year of their lives. State resources available to help meet the needs of the dying patient. spiritually emotionally. 4. emotional spiritual care provide physical. State resources available to help meet the needs of the dying 2. 1. our nurses may participate Palliative Hospice. physically. may participate in Palliative Care and Hospice. Part the care includes life care. not the last days.PROCEDURE: PROCEDUR: Date: Approved by: Approved NEEDS OF DYING PATIENTS AND End of Life Care DYING PATIENTS AND of Life NEEDS 111912009 Supersede: 10/1/2009 11/9/2009 Supersede: 101112009 ~~¿i Date:~ ~~iiJ Date:~ Needs Dying Patients Needs of Dying Patients and End of Life Care Learning Objectives: Learning Objectives: After reading this section Needs Dying Patients of Life Care. That it is our responsibility to meet the needs of the dying dying patient. patient. That patients often require additional support That patients often require additional support in the last years months need. emotional and spiritual care we provide to our patients patients in the last year of their lives. spiritually and emotionally.

14. clergy and their families: 1st st What dying have to to teach doctors. sensitive. after death. own way. The need to have all questions answered honestly and fully. 5. sensitive. even though the goals may change from "cure" to to "comfort" goals. 8. 16.The need toto die in peace and dignity.16. own way. 6. 8. focus may be.ed. The need to understand the process of of death. 1997 New York: Simon and Schuster. 6. E. The need toto know that the sanctity of the body wil be respected The need know that the sanctity of the body will be respected after death. however changing its its focus may be.The need not toto die alone. 12.Our Nurses areare encouraged read Kubler-Ross E. knowledgeable people. The need of children toto participate in death. the need to be cared for by compassionate. The need to seek spirituality. the need to be cared for by compassionate. On death and dying: Our Nurses encouraged to to read Kubler-Ross On death and dying: What thethe dying have teach doctors. 7. 11.be. even though the goals the need for continuing medical care. the need for continuing medical care. 5.10. The need participate in decisions concerning one's care. The need to participate in decisions concerning one's care. nurses. 1. The need to express feelings and emotions about pain in in one's The need to express feelings and emotions about pain one's own way.15. ======f=Ü~îÉ=êÉ~Ç=íÜÉ=~ÄçîÉ=mêçÅÉä=éçäáÅó=~åÇ=éêçÅÉÇìêÉ=Ñçê=ãÉÉíáåÖ=íÜÉ=åÉÉÇë=çÑ= ======ÇóáåÖ=é~íáÉåíë=~åÇ=ÉåÇ=çÑ=äáÑÉ=Å~êÉK |||||||||||||||||||||||||||||||||||============================|||||||||||||||||||||||| bãéäçóÉÉ=páÖå~íìêÉ=================================================================a~íÉ . 7. may change from "cure" "comfort" goals. The need to be cared for by those who can maintain a sense of of The need to be cared for by those who can maintain a sense hopefulness. however changing 2. The need to maintain sense hopefulness. however changing this may be. knowledgeable people. 4. however changing this may 4. The need toto be free of physical pain. 9. The need die in peace and dignity. The need of children participate in death. The need to be treated as a living human being. 9. The need to understand the process death. The need not die alone. 2. 3.11. The need to express feelings and emotions about death inin one's The need to express feelings and emotions about death one's own way. 3. New York: Simon and Schuster. The need to seek spirituality. The need to be treated as a living human being. 13.12. 10. nurses. clergy and their families: 1 ed. The need to maintain aasense ofof hopefulness. 1997 The Needs of thethe Dying Dying The Needs of 1. The need to have all questions answered honestly and fully.13. 15. hopefulness. 14. The need be free of physical pain.

California 90254 P: 310-372-0560 F: 877-707-5576 www. Inc.HIPAA Awareness Training I certify that I have received HIPAA Awareness Training. ____________________________________________________ First Name Last Name ____________________________________________________ Signature Date Procel Temporary Services. JCAHO CERTIFIED 2447 Pacific Coast Highway. I understand it represents mandatory policies of the organization and agree to abide by it.com . Suite #207 Hermosa Beach.procelnurses.

False 7.Copyright © 2010 Clearview Staffing Software Inc. including the right to decide what medical care or treatment to accept. Medical Power of Attorney. True B. reject or discontinue. A. When explaining a procedure to a preschooler it is okay to use technical medical terms. Lock the wheels B. For adults you should encourage as much self care as possible. True B. False 10. EXCEPT: A. tension building. EXCEPT: A. Lumbar C.p k~ãÉW|||||||||||||||||||||||||||||||||||||||||||||====`ä~ëëW|||||| Test Name: Comprehensive Core Competency . A. It is a federal law that adults over 18 years of age have the right to make their own healthcare decisions. A. False 3. Thoracic D. A. A. The following are guidelines for transferring patients from a dialysis chair to a wheelchair. Abdominal 9. True B. The patient should hold your waist C. True B. False 2. True B. Lower the patient into the wheelchair by slowly flexing your knees 8. Some other names for Advance Directives are: Out of Hospital DNR. A care plan should include discharge planning instructions. Completing a comprehensive assessment is the first step in the care planning process. True B. and calm. A. Living Will. All of the following natural curves are present in a normal spine. False 5. Seniors who are abusive to their caregivers can increase the caregiver's stress levels and has been known to contribute to abuse and neglect. making-up. Cervical B. A. True B. True B. False 6.Nursing Score: a~íÉW||||||||||||||||||||||||||| 1. False Nationally Validated Content . A. Page 1 of 6 . The cycles of domestic violence includes incident. Face the patient and spread your legs to increase support base D. False 4.

A. True B. The practicing of Autonomy is difficult for us when our patients choose alternatives that are in conflict with our own value system. Page 2 of 6 . False 14. Medical Equipment must be inspected every five years. It is okay for companies to give the hospital free products that the hospital charges the patients for. Justice C. A. True B. A. True B. All healthcare facilities use the same name for emergency and disaster codes. False 19.11. True B. False 17. A.Copyright © 2010 Clearview Staffing Software Inc. A. True B. The underlying core value of the Americans with Disabilities Act is based on the principle of: A. Respect for others D. Autonomy Nationally Validated Content . You can find information on proper chemical storage in the Material Safety Data Sheets (MSDS). False 13. Veracity B. False 15. True B. A. True B. False 18. You should always consider your patient's and their family's beliefs when giving your patient a bed bath. A. A. False 12. Verbal or written complaints concerning abuse or neglect are considered a grievance. A. It is important to understand how a patient interacts with their family when taking care of them. False 16. the supervisor should be notified of the issues. True B. Even if you are able to resolve a complaint. False 20. True B.

Professional Organizations C. A patient is admitted with a positive stool culture for Salmonella. Policies and Procedures D. A. All of the above 22. True B. Higher exposure to latex due to glove usage B. Which of the following is a contributing factor to a fall? A. Airborne precautions C. Soap and warm water 26. Accessible Protected Health Information (PHI) is limited to only information needed for performance of services. the best source to wash your hands with is: A. If a patient tells you they have a latex allergy. State Boards of Clinical Disciplines B. Alcohol based soap B. A. False 23.Copyright © 2010 Clearview Staffing Software Inc. you should: A. True B.21. Women are more prone to develop latex allergy and mostly women work in healthcare C. Restraints C. Bed Rails B. the identity of any physicians that have treated or are treating a patient. None of the above 27. False 25. Call the doctor to discharge them immediately B. Contact precautions B. If a patient has C. Put them on latex precautions 29. Page 3 of 6 . Why are healthcare workers at higher risk for developing latex allergy? A. True B. Which of the following types of transmission based precautions must be followed? A. Standards of Care are established by: A. They use more soap than others because of frequent hand washing 28. Not wear gloves when caring for them C. Diff. A. False 24. Brakes D. Side effects of some medications can increase a patient's risk for a fall. All of the Above Nationally Validated Content . It is acceptable to disclose to any third party. Droplet precautions D.

False Nationally Validated Content . True B. Accredited institutions are required to conduct a patient safety survey of the staff annually. False 37. True B. 2 33. and cultural values in the healthcare setting is important since it affects how the patient will respond to their care. A. Five D. nurses. Your best defense in any legal issue is: A. The assessment of pain is an interdisciplinary process including physicians. A. may have. spiritual. 10 B. 5 C. True B. Hospitals are required to perform how many FMEA(s) a year? A.Copyright © 2010 Clearview Staffing Software Inc. Two C. Quality Improvement focuses on collecting data. A.30. False 34. True B. False 32. A. Strong documentation B. A good memory C. False 35. Your facility's Exposure Control Plan is designed to protect all employees. as patients. False 38. Respect for the patient's psychological. and other clinical disciplines involved with the patient's care. One B. False 36. Page 4 of 6 . Moderate pain corresponds to which number on the numerical pain scale? A. Patients have the right and responsibility to report perceived risk of their care and/or safety issues or concerns they. A. 8 D. True B. Being certified in your field 31. Medication errors and adverse drug reactions are included in the scope of the patient safety plan. A. True B. A. Ten 39. True B. physical therapists.

and mental health disorders. Families and staff B. Staff and patients D.alcoholism.Copyright © 2010 Clearview Staffing Software Inc. Every 2 hours C. True B. All of the above 45. Aggressive behavior may occur between: A. False 44. All of the above 43. False 41. True B. Restraints can cause the patient's level of anxiety and confusion to increase. Protect employees D. addressing basic needs. Every hour B. False 47. True B. One sign that a nurse may be impaired is when patients complain that pain medication is not effective or deny receiving medication during that nurse's shift. Incident reports should NOT be placed in the patient's medical record. Risk Management is important to healthcare facilities in order to: A. True B. There are three major categories of impairment . A. Zero tolerance is a policy outlining what is and is not acceptable behavior in the workplace. You do not have to be the one being harassed to be a victim of sexual harassment. A. drug addiction. True B. Once a shift 42. Monitoring of restrained patients consists of documenting behavior. False Nationally Validated Content . True B. How often is this required? A. False 46. A. A. Improve care C. Every 4 hours D. Page 5 of 6 . Reduce costs B.40. False 48. A. and attempting or addressing alternatives. A. Patients and families C.

Tell the harasser that their conduct is unwelcomed B.49. you should first: A. If you feel you are being sexually harassed.Copyright © 2010 Clearview Staffing Software Inc. Medicare/Medicaid providers are required to conduct employee training on Compliance. Tell your supervisor C. A. Just quit and find another job 50. False Nationally Validated Content . True B. Page 6 of 6 .

Vital Signs during a procedure should be recorded. A. False 7. True B. A.k~ãÉW|||||||||||||||||||||||||||||||||||||| Test Name: Moderate Sedation Score: Date: _ a~íÉW||||||||||||||||||||||| 1. The nurse monitoring a patient should be able to demonstrate acquired knowledge of: A. every 15 minutes D. Pharmacology of drugs used for moderate sedation/analgesia B. The patient is pain free 9. When managing a patient receiving moderate sedation. Level of consciousness D. All the above are true 4. every 10 minutes C.Copyright © 2010 Clearview Staffing Software Inc. Cardiac arrhythmia interpretation C. Which of the following statements about midazolam (Versed) is true? A. May be reversed with flumazenil (Romazicon) D. Vital signs B. All of the above 8. how often? A. The primary goal of moderate sedation is to eliminate patient pain/discomfort during planned procedures. False 2. All discharge criteria are met C. A. False 6. Patients receiving moderate sedation do not need vascular access during the procedure. Page 1 of 2 . every 5 minutes B. Principles of oxygen delivery D. True B. Skin condition 3. Respirations are greater than 12 B. Excessive doses may lead to agitation and involuntary movement C. A. An informed consent must be signed prior to the administration of sedation. False Nationally Validated Content . None of the above 5. True B. True B. the nurse should monitor all of the following EXCEPT: A. Patients may be discharged by the post-procedural caregiver when: A. Blood gases C. Is a potent respiratory depressant B. Moderate sedation/analgesia is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands. Thirty minutes have elapsed post-procedure D.

A. Intravenous drugs should be given in small. False Nationally Validated Content . True B. False 12. True B. the patient will have q 15 minute vital signs until an Aldrete score of at least 9 and/or a pre-sedation level of consciousness/activity has been achieved. A. False 13. Page 2 of 2 . Patients may not be discharged for a minimum of 1 hour following the procedure unless specifically ordered by the physician. The response of patients to commands during procedures performed with moderate sedation serves as a guide to their level of consciousness.Name: -------------------------------Moderate Sedation Test Name: Score: Date: _ 10. A. True B. In the post-procedure phase. For patients receiving IV push sedation. A. incremental doses that are titrated to the desired end points. False 14. True B. True B. A.Copyright © 2010 Clearview Staffing Software Inc. False 11. a physician does not need to be present during the administration of the medication.

D. After the medical screening exam has been completed. Only if the patient is admitted as an inpatient at the hospital. even without the intention to break the rules. Yes. With regards to the EMTALA law and your work. 4. 5. 8. A. C. B. When the patient first comes to admissions. Fines. C. especially if the patient has Medi-Cal insurance since the hospital is not a Medi-Cal provider. All of the above. I may be in a position to deal with patients who come to the hospital for urgent care and I want to make sure that everything I say to the patient is compliant with EMTALA rules. Protect the financial health of the hospital B. Anyone in active labor. D. Health insurance at no cost to the patient B. so we can be sure to follow all the rules. C. There are many different types of patients who may be covered by the EMTALA rules. I want to provide safe and compassionate care to all who come to the hospital regardless of their ability to pay. Nothing B. we can never transfer a patient who is covered by EMTALA rules. Emergency Medical Transitional Labor (meaning pregnant women who are in labor) Act 2. which of the following statements reflects the law’s impact on your? A. B. All of the above. Which of the following are appropriate? A. 7. No. Page 1 of 2 . the hospital might suffer grave consequences. Ensure free health care for all 3. Can we transfer a patient covered by EMTALA rules? A. Never. D. EMTALA laws mandate what we must provide for patients who are covered by EMTALA rules. Emergency Medical Treatment And Labor (meaning pregnant women who are in labor) Act B.k~ãÉW|||||||||||||||||||||||||||||||||||||| Test Name: EMTALA Score: Date: a~íÉW|||||||||||||||||||||| 1. if we have permission from the receiving hospital and the qualified medical provider at the hospital provides a written certification that the benefits of transfer outweigh the risks of staying at the hospital. A medical screening exam by a qualified medical provider D. Yes. B. Protect the public from fraud C. What happens if we do not abide by the EMTALA rules? A. B. Prevent discrimination in health care D. Not much C. No electronic signature on record. loss of the ability to care for Medicare patients. If I break EMTALA rules. Anyone who brings up an urgent condition even if that person is not present in the ED but in another area of the hospital and/or visiting a friend/family. When is it safe to ask about insurance for any patient who comes to the ED? A. Anyone who presents to the ED with a complaint. The goal of the EMTALA law is to: A. C. A free transfer to another facility C. Select the answer that does NOT apply. Any treatment required to stabilize the patient 6. What do the letters EMTALA stand for? A.

parents upset. This is ABC Hospital and we do not have rape kits here. Page 2 of 2 . This is ABC Hospital and we do not admit children. were the EMTALA rules violated? A. Family is directed into Triage. She decided to leave before the MSE. B.” Patient replies. The patient was provided factual answers to her questions and offered a medical screening exam and was informed regarding her eventual transfer. 10.” Nurse documents this on her triage note. it isn’t and we do not admit children. the physician sees baby. D. However our physician will give you a medical screening exam and transfer you to XYZ Hospital. No. “I would rather drive my own car over to XYZ Hospital rather than wait here and get transferred. No electronic signature on record. In the above scenario. Have we violated EMTALA rules? In the above scenario. thus violating the EMTALA law. “Is this XYZ Hospital? Do you have rape kits?” The triage RN states. baby is examined and vital signs taken. Emergency Department Scenario A 23 year old women presents to the Emergency Department at 0500 asking. The information provided gave the patient the “I don’t want to wait and/or I shouldn’t wait option”. “Bring your baby back to the nearest Emergency Room if symptoms reoccur”. medication given and hydration given with improvement. Emergency Department Scenario A young couple arrives to the ED carrying a newborn infant. B. The initial information provided to the patient was not focused on the necessary initial medical screening (MSE) but on the “We don’t provide that level of care and you will just be sent elsewhere anyway”.Name: Test Name: EMTALA _ Score: _ Date: 9. In the above scenario the most appropriate response by the nurse is: A. Temperature 103. Yes B. “No. it isn’t. The nurse tells the family. No. C. No 11. This is ABC Hospital and a Physician will see your baby shortly. Yes. When the baby is ready for discharge the family was referred back to the clinic they came from for follow up. handing the RN a form from a neighboring clinic directing them to another neighboring hospital for sick infant with 103 fever. The father asks if the hospital they are now in is the neighboring hospital. baby lethargic. No. Did the nurses stay within limits of EMTALA rules and regulations? A.

Observe for bruising over the affected hip B. Capillary vasculature Nationally Validated Content . and pain in the injured extremity 6. and cover open wounds B. improving tissue perfusion.Copyright © 2010 Clearview Staffing Software Inc. Start an IV to provide fluid and electrolytes B. Genitourinary tract C. An elderly patient is brought to the Emergency Room after falling at home. Conduct a thorough physical assessment. probable head injury. the individual involved: A. The most important nursing measure at this time is to: A. and complaints of pain C. To assess for a hip fracture. and nasal passages D. mouth. Respiratory tract D. In order of priority. and arrange for emergency x-ray films 3. Pruritus D. obtain a history. Assist the physician in delivering intracardiac medications C. control accessible bleeding. Move the affected leg to see whether it causes pain D. The patient complains of severe pain in the hip and an inability to walk. A patient is admitted to the Emergency Room with multiple injuries including a crushed chest. Should be protected from flexion and hyperextension of the spine D. and fluctuating vital signs D. Drowsy but easily aroused.k~ãÉW||||||||||||||||||||||||||||||||||||||||||| Test Name: Emergency Room `çãéÉíÉåÅó=bñ~ã Score: Date: _ a~íÉW|||||||||||||||||||||| 1. Start an IV. Hypertension 7. stable vital signs. Can be transported in sitting position B. Page 1 of 5 . Suction the endotracheal tube. Call the pediatric ICU to inform them of the child’s admission 5. and multiple fractures. During the initial assessment of a 70-year-old male who is being re-admitted with hematemesis and bright-red rectal bleeding. Petechiae C. the nurse would: A. Elevated temperature. apprehension. The nurse knows that a patient on long term anticoagulant therapy must be carefully monitored for potential hemorrhage complications that most commonly affect the: A. the nurse should be particularly alert for: A. When evaluating the patient’s response to the Emergency Room treatments. Observe for shortening of the affected leg C. A patient is admitted to the Emergency Room with head and chest injuries received in an automobile accident. is intubated and bagged with 100% oxygen. who has a pulse of 50 beats per minute but no spontaneous respirations. which assessments indicate that the patient can safely be transferred to a critical care unit? A. Stable vital signs. and cyanosis B. After an accident in which there is a question of back injury. abdominal trauma. GI Tract B. Facial flushing B. assess vital signs. The child. and obtain a history D. Assess vital signs. A child who was found face down in a water ditch is brought to the Emergency Room. slowing pulse and respirations. May be transported in any position because position in not important 4. Move the affected leg to feel and hear crepitus 2. and determine the presence of critical injuries C. the initial emergency care interventions for this patient are to: A. Alert but restless. get blood for typing and cross matching. May be transported best when placed in a side-lying position C. Assess vital signs.

Copyright © 2010 Clearview Staffing Software Inc. The presence of excessive drooling B.Name: Test Name: Emergency Room Competency Exam _ Score: Date: _ 8. Control of patient flow through the emergency department. The absence of tears C. Diabetic reactions B. A patient is receiving intravenous potassium chloride for the treatment of hypokalemia. The goals of triage include all of the following EXCEPT: A. The major objective during the emergent phase of a burn is to: A. Relieve pain B. Page 2 of 5 . Which treatment would the nurse expect a physician to order for a suspected cocaine overdose patient? A. A slightly increased respiratory rate D. Head injury C. Altered level of consciousness 9. A slowed heart rate Nationally Validated Content . Oxygen B. Activated charcoal 13. Assignment of patients to appropriate care areas within the emergency department C. B. Constricted pupils C. Which of these rhythm strip changes should the nurse expect to observe if the patient develops hyperkalemia? A. Shortened PR interval B. Elevated systolic blood pressure B. Lethargy and obtundation B. A clinical sign that would indicate a child is suffering severe dehydration is: A. Replace blood loss D. 14. Drug overdose D. Performing and documenting secondary survey on all patients who come to triage D. Determination of the urgency of the patient's condition. Altered respiratory pattern D. Which sign is typically the first indication of increased ICP? A. Peaked T waves C. Naloxone C. Which condition commonly mimics the signs and symptoms of alcohol intoxication? A. Restore fluid volume 12. Prominent U wave D. Elevated body temperature C. Prevent infection C. Euphoria and restlessness 11. All of the above 10. Physostigmine D. Elevated ST segment 15. Hypothermia and tiredness D. Which symptom of cocaine abuse would the nurse expect to detect during a patient assessment? A.

Copyright © 2010 Clearview Staffing Software Inc. Biting the tube 21. A patient complains of a sudden headache one minute after a drug is administered. Decreased secretions C. Based on this history. Involve the patient's family or significant others (with patient consent) with the discharge instructions that are being given to the patient D. Acetaminophen (Tylenol) C. Brown recluse spider D. Assessing the patient's neurological status B. Assessing vital signs 20. A 15-year-old boy who was stacking wood 2 days ago presents to the emergency department complaining of a painful ulceration on the dorsal surface of the second digit of his right hand. Identifying all injuries C. Your patient is on a ventilator. Blue scorpion C. If the patient does not speak English. Pulmonary edema B. Page 3 of 5 . Serial arterial blood gases C. Quinidine C. When establishing and maintaining adequate airway. and circulation for trauma victims. Ketorolac tromethamine (Toradol) 22. Lidocaine B. Digoxin 17. breathing. Nitrates D. Which of the following drugs would MOST LIKELY cause this symptom? A. Coagulation studies D. the emergency nurse should give equal priority to: A. Back widow spider B. Hydromorphone hydrochloride (Dilaudid) B. Methods that the emergency room nurse may use to reinforce discharge instructions include: A. Maintaining cervical spine precautions D. encourage him/her to contact a translator when he/she returns home to explain the instructions to him 19. A disconnected tube D. Tell the patient to call their physician or nurse practitioner if there is anything they do not understand about their care in the emergency room C.Name: -----------------------------------Emergency Room Competency Exam Test Name: Score: Oate: _ 16. Which of these medications in a patient's history would be associated with hematemesis? A. Wolf spider Nationally Validated Content . This may be due to: A. Which of the following assessment parameters may be used by the emergency department nurse to evaluate the toxicity of an acetaminophen poisoning? A. Liver Function Test B. the most likely thing that may have bitten him is: A. The low volume alarm sounds. Meperidine hydrochloride (Demerol) D. Electrolytes 18. He has no other complaints. Give only oral instructions when discharging a patient from the ER B.

Tooth loss B. Decrease in patient's core body temperature from the application of heat C. Notify the parents about her concern B. The nurse's most immediate concern for a patient sustaining a LeFort fracture should be: A. The purpose of charcoal in the care of the poisoned patient is to: A. An injury where skin is peeled away from an extremity is: A. When a child presents to the ER and abuse or neglect is suspected. Contusion B. Injury to the patient's skin from heat application because of the initial peripheral vasoconstriction D. Nausea and vomiting Nationally Validated Content . Paroxysmal coughing B. Seizure activity D. Absorb toxins from the gastrointestinal tract B. Tooth malocclusion D. Prevent cardiac dysrhythmia that may result from absorbed toxins D. Consult with an attorney to protect herself from a lawsuit 28. One of the best ways to prevent misinterpretation of patient care situations is to: A. Sternocleidomastoid retractions C. Report to the appropriate authorities C. Call the supervisor to witness any unusual events C. A late sign or symptom of hyponatremia is: A. What specific physical signs may indicate respiratory distress in the adult asthmatic patient? A. the emergency nurse must: A. Hypertension B. Page 4 of 5 . Neck vein distention 24.Copyright © 2010 Clearview Staffing Software Inc. caution must be exercised to prevent: A. Audible wheezing D.Name: Test Name: Emergency Room Competency Exam _ Score: Oate: _ 23. Laceration C. Complete an exception report as a routine part of the chart 25. When using active external re-warming devices. Additional vasoconstriction in the affected extremities from the application of heat B. Avulsion 26. Clearly and concisely document what happened B. Airway management C. Ask the physician to add information to their dictation D. Obtain the appropriate consent for further treatment D. Decrease the possibility of bleeding from the absorbed toxins 30. Hyperactivity C. The development of hypertension from heat application 27. Abscess D. Uncontrolled epistaxis and resultant hypovolemia 29. Induce vomiting and remove all the remaining toxins C.

Normal sinus rhythm C. Bradycardia 32. Name this rhythm: A.8 degrees. Ectopic pregnancy D. or diarrhea but reports moderate spotting over the past 24 hours.Name: ------------------------------Emergency Room Competency Exam Test Name: Score: Date: _ 31. Ruptured ovarian cyst 33. Her vital signs include blood pressure of 124/84. Based on these assessment findings. Respiratory syncytial virus (RSV) is NOT transmitted by: A. 1st degree heart block B. What is the principal cause of a radial head dislocation in children? A. P 90. She denies nausea. 3rd degree heart block D. Page 5 of 5 . Visitors D. Her last menstrual period was 2 months before the onset of symptoms. Endometriosis C. and temperature 98. Hand washing Nationally Validated Content . Large droplet aerosols B. A fall onto an outstretched forearm C. A blow to pronated forearm D. vomiting. the emergency nurse should suspect: A. Dysmenorrhea B. A pull on a pronated forearm B. A crush injury to a supinated forearm 34. Sneezing C.Copyright © 2010 Clearview Staffing Software Inc. A 24-year-old woman complains of crampy pain in the right lower quadrant for the past several hours.

Which of the following drugs would MOST LIKELY cause this symptom? A.k~ãÉW||||||||||||||||||||||||||||||||||||||||||| Test Name: Emergency Room Medication Score: Date: _ a~íÉW||||||||||||||||||||||||| 1. The nurse should anticipate that the patient would receive: A. GI Tract B. Atropine Sulfate C. Epinephrine B.Copyright © 2010 Clearview Staffing Software Inc. Which of these rhythm strip changes should the nurse expect to observe if the patient develops hyperkalemia? A. Increasing peripheral resistance D. Digoxin 3. Respiratory tract D. The nurse recognized that this drug decreases blood pressure by: A. Acetaminophen (Tylenol) C. Which of the following assessment parameters may be used by the emergency department nurse to evaluate the toxicity of an acetaminophen poisoning? A. A patient with a history of hypertension comes to the Emergency Room with double vision and a blood pressure of 260/120 mm Hg. Nitrates D. A patient complains of a sudden headache one minute after a drug is administered. Ketorolac tromethamine (Toradol) 5. Hydromorphone hydrochloride (Dilaudid) B. the physician orders a Sodium Nitroprusside infusion. Lidocaine Hydrochloride Nationally Validated Content . Relaxing venous and arterial muscles 7. Genitourinary tract C. The nurse knows that a patient on long term anticoagulant therapy must be carefully monitored for potential hemorrhage complications that most commonly affect the: A. Coagulation studies D. Which of these medications in a patient's history would be associated with hematemesis? A. Sodium Bicarbonate D. Peaked T waves C. Liver Function Test B. Elevated ST segment 6. Capillary vasculature 2. Increasing cardiac output B. Decreasing the heart rate C. Page 1 of 6 . Shortened PR interval B. Lidocaine B. A patient is receiving intravenous potassium chloride for the treatment of hypokalemia. Electrolytes 4. Prominent U wave D. Meperidine hydrochloride (Demerol) D. In addition to other drugs. Quinidine C. Serial arterial blood gases C. A patient brought to the Emergency Room develops premature ventricular Beats (PVBs) after arrival.

000 units of heparin in 500 ml of dextrose 5% in water (D5W) to infuse at the rate of 1. Valproic acid (Depakene) 13. 24 mls per hour C. 2 mls C. 0.1 mg/kg. 2 ml 11. Magnesium sulfate C. How many ml's would you give? A. Synthroid is available in 500mcg/ml vial. 125 mls D. The order reads: Tylenol elixir 350 mg via NGT. 21 mls C.8 mls 12. 218 mls D. 2. 20 mls 10.1 ml B. The available 10 ml vial of Norcuron containes 1 mg/ml. Diazepam (Valium) D. 15. 15ml B.5 mls B. Phenytoin sodium (Dilantin) B. Bumex is available in 0. 20 mls per hour D. 0. 0.75mgIV.Name: Test Name: Emergency Room Medication _ Score: Date: _ 8.2 ml C. 1.7 ml D. 6 mls per hour 9. The drug of choice for a pregnant patient who has seizures associated with pregnancy-induced hypertension is: A. Page 2 of 6 . A 154lb patient has been sedated and is now being paralyzed with vecuronium bromide (Norcuron). He orders 25.Copyright © 2010 Clearview Staffing Software Inc.5 ml C. 7 mg C. How many ml's would you give? A. Haldol is available in a 5mg/ml ampule. 21.15ml D. Tylenol elixir is available in 80 mg/5ml bottles. 12 mls per hour B. 0.18 mls B. 1 ml D.000 units/hr. The recommended initial dose is 0.25 mg/ml vials. 0. 12. How many ml's would you give? A. The flow rate in milliliters per hours is: A. The physician orders a heparin infusion. The order reads: Synthroid 0.4 ml Nationally Validated Content . How many ml's would you give for this dose? A. 150 ml 14.07 ml B. The order reads: Bumex 5 mg IV. How many milliliters shoud the patient receive? A. The order reads: Haldol 1 mg IV.

Q waves less than 0.5 ml C. 90 mg C. 1ml B. The patient weighs 60 kg. Tachycardia 16. Deferoximine C. 900 mg D. Dexamethasone (Decadron) C. Page 3 of 6 . Absence of ventricular dysrhythmias 19.Name: ------------------------------Emergency Room Medication Test Name: Score: Date: _ 15. Acetylcysteine B. How many mg will be given? A. 1 mg 20. The order reads: Vancomycin 15 mg/kg over 1 hour x1. Tachypnea B. Diazepam B. Hypertension D. One indicator of myocardial reperfusion during thrombolytic therapy is: A. 1000 mg B. Take several days to be effective 18. The emergency nurse should instruct the patient that phenazopyridine would: A. The nurse is aware that Tylenol poisoning is treated first with: A. How many ml's would you give for this dose? A. Activated charcoal Nationally Validated Content . The order reads: Digoxin 0. A female patient diagnosed with a urinary tract infection (UTI) is being discharged from the emergency department and will be treated with ampicillin and phenazopyridine. Treat her fever and chills D. Bradycardia C.25 mg IV Digoxin is available in a 0. 2 ml D. 0. Prothrombin time greater than 25 seconds D. 600 mg 17. Edetate calcium disodium D.5mg/2ml ampoule. A child is admitted to the emergency room following ingestion of a bottle of Children's Tylenol. Relief of chest pain B. Decrease her needs for drinking additional fluids B.04 seconds in width C. Turns her urine orange C. Phenytoin D. Phenobarbital 21. Which drug is the treatment of choice to prevent seizure from traumatic head injury? A. An infusion of phenytoin (Dilantin) at a rate greater than 50 mg/min for an adult may result in which of these side effects? A.Copyright © 2010 Clearview Staffing Software Inc.

A. His ECG reveals atrial fibrillation with a ventricular response rate of 130 beats per minute. Page 4 of 6 . To treat general discomfort B. To treat nausea 24. While he is receiving quinidine. (Pulseless electrical activity). the nurse should monitor his ECG for: A. The patient is admitted to the emergency room with shortness of breath. and tachycardia. What is the MOST important nursing goal for a patient in septic shock? A. Peaked P wave B. Flushing B. Dyspnea C. The physician orders quinidine sulfate. Nitroglycerin D.E. Lidocaine C. the nurse would carefully monitor for the common side effect of: A. Hypotension 25. For a patient in P. an adverse effect to immediately watch for is: A. The nurse is aware that the reason for this order is: A. Dopamine B. Hypertension 26. Amiodarone D.I. To prevent stress ulcers D. His physician prescribes a histamine blocker. The patient is admitted from the emergency room with multiple injuries sustained from an auto accident. and hemodynamic stability B. Elevated ST segment C. Tachycardia D.Name: ------------------------------Emergency Room Medication Test Name: Score: Oate: _ 22. After the administration of epinephrine to a child with asthma. Prolonged QT interval 23. ventilation. anxiety. Tremors B. All of the above 27. Tachycardia D. To correct electrolyte imbalances C. Epinephrine 28. When administering an intravenous titrated drip of Lidocaine HCL to a patient. Inverted T wave D. Anorexia C.Copyright © 2010 Clearview Staffing Software Inc. To maintain accurate intake and output records and to optimize support C. To prevent skin and soft tissue breakdown D. Oxygen C. To promote adequate tissue perfusion and support oxygenation. treatment? A. which medication would be given first? A. To promote comfort and provide psychosocial support to the patient and family Nationally Validated Content . Which of the following is appropriate for acute M. Morphine B.

Copyright © 2010 Clearview Staffing Software Inc. Which finding indicates the direct effectiveness of the drug? A.5 times the normal dose 30. Nitroglycerin C. The physician has ordered Activase (alteplase) for a patient admitted with a myocardial infarction. 3 to 3. decreases myocardial workload by decreasing venous capacitance and increasing systemic vascular resistance 34.5 ml/hr Nationally Validated Content . Increased pulse rate B. Epinephrine 31. Morphine relieves the anxiety a patient feels secondary to a catecholamine release. Page 5 of 6 . Furosemide D. Morphine relieves anxiety and decreases myocardial workload by vasodilating the pulmonary arterial tree D.5 times the normal dose C. Increased urinary output C.5 times the normal dose B. Morphine relieves the anxiety a patient feels secondary to a decrease in catecholamine release. Lysis of the clot 33. Morphine B. The physician has ordered an infusion of Osmitrol (mannitol) for a patient with increased intracranial pressure. Stabilization of the Vessel Tunica Intima D. The dosage available is Dopamine 800 mg to be mixed in 250 ml of Normal Saline. 10 ml/hr C. 1 to 1. A patient weighing 40 kilograms is to receive Dopamine at 7 micrograms/kg/min. Decreased diastolic blood pressure D. decreases myocardial workload by increasing venous capacitance and reducing systemic vascular resistance B. What is the infusion rate? A. Morphine relieves anxiety and decreases workload of the heart through a diuretic effect C. 5. Prevention of congestive heart failure B. 5 ml/hr D. Abciximab (ReoPro) C.Name: Test Name: Emergency Room Medication _ Score: Date: _ 29. Which of the following is a true statement in relation to the positive effects of Morphine Sulfate in a patient who has experienced a myocardial infarction? A. Aspirin 35. Increased pupil size 32. The desired effect of Activase is: A. the dose should be increased at: A. Eptifibatide (Integrilin) D. When administering medications via the endotracheal tube. Ticlopidine (Ticlid) B. 10.5 times the normal dose D. Stabilization of the clot C. All of the following medications may be helpful in the treatment of acute pulmonary edema EXCEPT: A. 4 to 4.25 ml/hr B. Which of the following drugs is now considered the standard therapy for unstable angina and after treatment of a MI? A. 2 to 2.

if administered. A patient is admitted to the hospital with pneumonia and congestive heart failure and requires mechanical ventilation. Mannitol 37. the more you increase the Dopamine. Your patient is on a Dopamine drip for hypotension. Administering additional fluids D. 3. Doing nothing and see if the patient stabilizes C. Giving another more potent drug such as Neosynephrine 39. However. Syrup of ipecac 40. 580 mls B. Which of these antidotes. Premixed Heparin drips are available with Heparin 25. would bind with the toxic metabolites released from the medication? A. Pepcid D. A child has been diagnosed as having acute acetaminophen (Tylenol) poisoning. how many ml's per hour would you administer? A. Bleeding gums C. Change in mental status 38. Which of the following should you immediately report to the physician? A. 34 mls Nationally Validated Content . Page 6 of 6 . Acetylcysteine (Mucomyst) B. Continuing to increase the drip because the patient may need more alpha effect B. 58 mls D. Ibuprofen (Advil) C.4 mls C. A patient is receiving tenecteplase (TNKase) 3 hours after an acute MI.Name: ------------------------------Emergency Room Medication Test Name: Score: Date: _ 36.Copyright © 2010 Clearview Staffing Software Inc. Which of the following medications would you anticipate the patient receiving? A. Magnesium citrate D. You should consider: A. The order reads: Heparin 1700 units/hr. Tetracycline B. PVC’s B.000 units/500ml. Oozing at the insertion site D. the lower the BP drops. Sodium Bicarbonate C.

• If your total income will be less than $61. . but withhold at higher Single rate. (Entering “-0-” may help you avoid having too little tax withheld. . . But. . or two-earners/multiple jobs situations. see Notice 1392.gov/w4. and I certify that I meet both of the following conditions for exemption. for more information. see the Deductions and Adjustments Worksheet on page 2. . Supplemental Form W-4 Instructions for Nonresident Aliens.Form W-4 (2012) Purpose. state. E Enter “1” if you have at least $1. . • If you plan to itemize or claim adjustments to income and want to reduce your withholding. figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. 7 Under penalties of perjury. before completing this form. Child and Dependent Care Expenses.000 (Single) or $180. 505 for information on converting your other credits into withholding allowances. . then less “1” if you have three to seven eligible children or less “2” if you have eight or more eligible children. F (Note. 6 $ I claim exemption from withholding for 2012. complete only lines 1. . . . see Pub. and Filing Information. C Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . Check your withholding. You must call 1-800-772-1213 for a replacement card. 3.) Child Tax Credit (including additional child tax credit). . . If you are a nonresident alien. . . withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages. . D Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . . 10220Q VR=QONRQRO Form W-4 (2012) . Tax Withholding and Estimated Tax. Head of household. . 4.) . interest and dividends). . have only one job. . 1545-0074 1 Your social security number 3 Single Married Married. A • You are single and have only one job. Two earners or multiple jobs. 5 6 7 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 5 Additional amount.gov for information about Form W-4.000 ($90. . . You can take projected tax credits into account in figuring your allowable number of withholding allowances. correct. 505 to find out if you should adjust your withholding on Form W-4 or W-4P. certain credits. See Pub. see page 2. • Last year I had a right to a refund of all federal income tax withheld because I had no tax liability. . . you want withheld from each paycheck .000 if married). Generally. . Keep the top part for your records. . and 7 and sign the form to validate it. . Personal Allowances Worksheet (Keep for your records. you can claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. .) Date mêçÅÉä=kìêëÉë=ö=OQQT=m~ÅáÑáÅ=`ç~ëí=eïó=pìáíÉ=OMT=eÉêãçë~=_É~ÅÜI=`^=VMORQ For Privacy Act and Paperwork Reduction Act Notice. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted on that page. 2013. . . for details. enter “2” for each eligible child. . . .000 (Married). see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld. See Pub. 505. Your exemption for 2012 expires February 18. After your Form W-4 takes effect. If you meet both conditions. . G H For accuracy. you may claim fewer (or zero) allowances. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. • If neither of the above situations applies. check here. at www. or • You are married. . . 501.000 if married). Consider completing a new Form W-4 each year and when your personal or financial situation changes. . Employee’s signature (This form is not valid unless you sign it. . . complete the Personal Allowances Worksheet below. However.900 of child or dependent care expenses for which you plan to claim a credit . H • If you are single and have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed $40. Tax credits. you cannot claim exemption from withholding if your income exceeds $950 and includes more than $300 of unearned income (for example. Separate here and give Form W-4 to your employer. and • This year I expect a refund of all federal income tax withheld because I expect to have no tax liability. See Pub. . No. I declare that I have examined this certificate and. 505.000 ($10. . . . income. . Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. if any. . If you are not exempt. . it is true. See Pub. . If another person can claim you as a dependent on his or her tax return.irs. Complete all worksheets that apply. For regular wages. . . . See Pub. Form Department of the Treasury Internal Revenue Service Employee's Withholding Allowance Certificate Whether you are entitled to claim a certain number of allowances or exemption from withholding is subject to review by the IRS. 505 for details. write “Exempt” here . The IRS has created a page on IRS. Basic instructions. Future developments. See Pub. use Pub. Child Tax Credit. B • Enter “1” for your spouse. . . . . . . . 972. Cat. complete all worksheets that apply. . and your spouse does not work. adjustments to income. . and complete. especially if your earnings exceed $130. or Enter “1” if: . Standard Deduction. Do not include child support payments. and ZIP code OMB No. . Exemptions. 2. . . . Exemption from withholding. If you are exempt.) A B C D E F G Enter “1” for yourself if no one else can claim you as a dependent .) 8 Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS. stop here and enter the number from line H on line 5 of Form W-4 below. 505 to see how the amount you are having withheld compares to your projected total tax for 2012. Last name 2 Your first name and middle initial Home address (number and street or rural route) City or town. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. for information. . Your employer may be required to send a copy of this form to the IRS. you may choose to enter “-0-” if you are married and have either a working spouse or more than one job. 4 If your last name differs from that shown on your social security card. . Note. Nonresident alien. . The worksheets on page 2 further adjust your withholding allowances based on itemized deductions. . . 503. . If you have a working spouse or more than one job. to the best of my knowledge and belief. See Pub.

and if the employee presented document(s). Section 1. Preparer's/Translator's Signature Print Name Address (Street Name and Number.) Signature of Employer or Authorized Representative Print Name Title Date (month/day/year) Business or Organization Name and Address (Street Name and Number. (State (month/day/year) employment agencies may omit the date the employee began employment. To be completed and signed by employer. under penalty of perjury. Print Name: Last First Middle Initial Maiden Name Address (Street Name and Number) Apt. Zip Code) Date (month/day/year) Section 2. under penalty of perjury. under penalty of perjury. 1615-0047. Date of Rehire (month/day/year) (if applicable) C. of the document(s). City. State. # Date of Birth (month/day/year) City State Zip Code Social Security # I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form. that I have examined the document(s) presented by the above-named employee. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work eligible individuals. To be completed and signed by employee at the time employment begins. City. New Name (if applicable) B.S. Employee Information and Verification. State. Zip Code) Section 3. 06/05/07) N . Signature of Employer or Authorized Representative Date (month/day/year) Form I-9 (Rev. (To be completed and signed if Section 1 is prepared by a person other than the employee. that the employee began employment on and that to the best of my knowledge the employee is eligible to work in the United States. provide the information below for the document that establishes current employment eligibility. number and expiration date.) I attest. that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct. Employment Eligibility Verification Please read instructions carefully before completing this form. Employers CANNOT specify which document(s) they will accept from an employee. If employee's previous grant of work authorization has expired.I attest. that to the best of my knowledge. if any. List A OR List B AND List C Document title: Issuing authority: Document #: Expiration Date (if any): Document #: Expiration Date (if any): CERTIFICATION .OMB No. Examine one document from List A OR examine one document from List B and one from List C. Updating and Reverification. Expires 06/30/08 Department of Homeland Security U. Employer Review and Verification. Document Title: Document #: Expiration Date (if any): l attest. Employee's Signature I attest. this employee is eligible to work in the United States. Citizenship and Immigration Services Form I-9. A. the document(s) l have examined appear to be genuine and to relate to the individual. as listed on the reverse of this form. and record the title. that the above-listed document(s) appear to be genuine and to relate to the employee named. that I am (check one of the following): A citizen or national of the United States A lawful permanent resident (Alien #) A An alien authorized to work until (Alien # or Admission #) Date (month/day/year) Preparer and/or Translator Certification. The refusal to hire an individual because the documents have a future expiration date may also constitute illegal discrimination. To be completed and signed by employer. The instructions must be available during completion of this form. under penalty of perjury.

When I work a twelve (12) hour shift. I understand that I may revoke this at any time. When I work over six (6) hours in one day. _____________________________________________________________ First Name Last Name _____________________________________________________________ Signature Date . I will continue to take my rest breaks. This will be in effect my first day of employment with PROCEL. I agree to take a thirty-minute meal period and will waive a second thirty-minute meal period. I would prefer to waive my meal break when I work less than six (6) hours per day.Meal Break Agreement I understand that I am entitled to one meal period per eight (8) hour shift that I work. I agree to take my thirty-minute meal period.

and I authorize and respect BANK to accept any credit entries initiated by COMPANY to such account without responsibility for the correctness thereof. I also understand that if I fail to notify PROCEL of these changes I may not receive my direct deposit pay. I recognize. IMPORTANT!!! ATTACH VOIDED CHECK FOR CHECKING ACCOUNT OR ATTACH DEPOSIT SLIP FOR SAVINGS ACCOUNT Name of Institution: ______________________________________________________ Employee Name: _________________________________________________________ Account #: __________________________ Routing #: __________________________ Account Type: Checking Savings Cancel Direct Deposit Direct Deposit will be tested the first week. Closing. the COMPANY has notified me of the correction and the reason therefore: and. This is called a “Pre-Note”. PROCEL cannot guarantee that your bank will post the direct deposit in your account on Fridays. acknowledge. The purpose is to ensure your correct account. Company ID#: ______________ I hereby authorize the COMPANY. If test is successful the direct deposit will be activated the following week. Account #. to make payments of any amount owing to me by initiating credit entries to my account indicated in the bank names below. I also authorize and request COMPANY to effect repayments to COMPANY for any amounts owed it because of prior erroneous credit initiated to my account if prior to initiation of the correcting entry. Therefore. PROCEL. Name: __________________________________________________________________ Signature: ______________________________________ Date: ___________________ Revised 10/2008 LB . hereinafter called BANK. arising from any act or omission by the COMPANY and/or PROCEL and their employees. and accept that this service is being provided for my convenience. PROCEL will process direct deposit every payday (Thursday). I agree to hold the COMPANY. the correcting entry is transmitted in such time as to be delivered or make available to BANK before midnight of the tenth day next following for the erroneous entry. etc. As such. including without limitation any claim based on an alleged loss as a result of non-credit of any deposit. It is understood that either party may terminate this agreement at any time by written notification to COMPANY or BANK. Friday is usually the day our employees receive their direct deposit pay.Authorization Agreement for Automatic Direct Deposit Company Name: Procel Temporary Services Inc. please ask your bank representative when you can expect your money to be deposited into your account. Any such notification to BANK shall be effective only with respect to entries credited into my account by BANK after receipt of such notifications and reasonable time to act on it. I understand that is it my responsibility to notify PROCEL of any changes related to my direct deposit: Bank. each participating bank and NACHA harmless from any claim incident to the operating of this plan. Any such notifications to COMPANY shall be effected only with respect to entries initiated by COMPANY after receipt of such notification and reasonable opportunity to act on it. and any claim which ay be made by any depositor as a result the rejection of any of his debits because of insufficient funds arising from failure to credit deposits to my account. Thereafter.