CPK Scenario 4 Reassess its VS Report suspicion of abuse to adult protective services Use therapeutic communication/active listening understanding Assess pt's ABCs Scenario 3 Contact social services Linda Pittmon Room 304 Glucose level? Impaired skin integrity: False Call RRT Scenario #3 Ensure no one in the room is touching the pt or the bed and cardiovert Mr. Raymond, COVID-19 to apply Diet plan? Full assessment Scenario 5 2-Ensure UAP has proper PPE -Initiate alternative distractions for pain / anxiety interventions Grieving: False Explain reason You have entered the room to administer the pts morning medication, atenolol 50mg. Educate pt. Document and accompany pt to ICU immediately, and handoff report to receiving ICU nurse, Educational Needs: Increased acuity Impaired Mobility: True Contact hospice/social work Neurological - normal, Impaired mobility, risk for Educational needs: Increased acuity Impaired acute confusion: False Fear: True Take VS Scenario 2 Offer masks Imbalanced Nutrition: False Request order Psychological Needs: Increased acuity Scenario #3 4-Remove the dressings reassess the burns. Ensure signed consents are on the chart Contact assisted living Deanna Concept Map Assignment 1. Scenario 5 Call rapid response - Neurological - increased After washing and gloving hands, you then identify yourself and the patient, Ann Rails. Impaired mobility, risk for Upon enter the room, she asks you if she will be able to drive when she gets home tomorrow. on enteric, Acute pain Pt. Provide an exercise routine Provide emotional Evaluate pt. Constipation: False Administer nebulizer During the follow up nursing assessment, Ms. Hatcher complains about the NG-tube causing her pain in her nasal area. Reassess pt's VS's and pain level Ensure documentation Health Change - increased - Powerlessness She was asymptomatic upon arrival. View new-patients-swift-river-med-surg-covid-new-patients-charlie-raymond-john-duncan-carlos-mancia-kenny from NURSING 11B at Long Beach City College. Instruct pt not to get out of bed w/o assistance -Contact the appropriate department to see the status of the advance directive Mrs. Stukes's husband is not willing to help assist pt upon d/c w/ her stoma care for failed laparoscopic cholecystectomy. . Ineffective Breathing Pattern: False Compromised family coping Inspect site Impaired comfort, risk for Encourage fluids Scenario #3 Monitor and evaluate fluid intake Wash and glove hands Take VS & provide pt. Order for a Foley catheter has been obtained and Lucy Jones, LPN, is their to assist. Prepare and administer Donald Lyles 5. Initiate large bore IV Electrolyte Imbalance True Collect supplies Psychological Needs: Normal acuity, Physiological Nausea, Scenario #1 Evaluate pt. Transport Mr. Burgandy Chronic Pain: False Discuss support, Acute pain 2-The patient has survived a mass shooting Describe to pt. Contact surgeon Risk for Infection: True -Coping Chronic pain: False Document results/findings Upon entering the room, you find Mr. Sturgess is quiet, appears tense and rigid but states, "I am feeling fine." Have IV abx amiable to administer when surgery calls for the pt to be transferred to pre op area. Mr. Lyles responded to the first cardioversion, and is now in a sinus-Brady w/ a second-degree heart block. Swift River_2020 | NURS 320 Med_Surg_Swift_River_Graded A - Qwivy.com Scenario #5 -Reapply Silvadene and sterile dressings. Full assessment Fall Risk - increased Perform initial Deficient knowledge, Scenario #1 Scenario 5 Scenario 4 She was admitted yesterday for . Love and belonging- Orient patient to utensils and location of food on tray Don new gloves Explain to Mrs. Whitmore Deficient diversional activity: False Pain Level: Normal acuity -Call RRT and prepare SBAR -Administer pain medication and call provider for a fentanyl or hydromorphone hydrochloride prescription. Safety: Increased acuity, Physiological - Assess pleurovac Fall - increased Scenario #3 Fluid & electrolytes Provide emotional support Inspect pleurovac Health Change: Increased acuity Carlos Mancia 11. -Have UAP use therapeutic communication Educate caller regarding HIPAA Scenario #3 Evaluate pt. She is experiencing polyphagia and polydipsia with blurred vision Scenario 4 Mr. Martinez lab work comes back post-stent placement Sensorium: Increased acuity, Educational Needs: Increased acuity Grieving Alert ICU You responded correctly to 5 out of 6 evaluations: The high blood glucose alters the patient's pH, Altered by the high blood glucose as a result of dehydration from, Low glycemic intake is recommended for the long-term, Mrs. Workman's blood sugar is 560 DL; her rash has extended over her abdomen. 2. Call HCP Pain level: Increased acuity Remain w/ pt. Ineffective self-health mgmt: True Scenario #3 Repeat neuro Scenario 5 Scenario 1 He says, "I take TUMS at home when this happens." Mrs. Smith shares w/ you that even though she signed the operative consent she was not sure if this was the right surgical procedure for her. Document Auscultate lungs Assess understanding Evaluate potential barriers Obtain a sitter Ask Mrs. Workman for 24-hour diet Constipation: False Scenario #5 Charge the monitor Reassess pt's VS Educate pt regarding condition The HCP prescribed the following orders, place in implementation sequence: Anxiety: True Impaired Mobility, Risk for: True Scenario #3 4.) Take VS Review plan of action Place pt. -Rate patient's pain on a scale of 1-10To determine level of pain for intervention Explain to Roger Health Change - increased Administer the medication Acute Pain: True Assess/inspect Comfort the pt Pain - increased Contact HCP Esteem- - Constipation, risk for Provide emotional support The nurse auscultation fine crackles in her lungs bilaterally, but her sputum is clear. Richard Dominec Sensorium - normal, Enhanced readiness for learning - Ineffective health maintenance Scenario #5 Include pt. Initiate IS treatment Initiate O2 @ 2LNC Assess current pain Pt sates pain has been managed through the night. -Record what and how much the patient eats Use therapeutic Assessment of bowel movement Sensorium - normal, Deficient fluid volume Assess and document Linda Yu | Mary Barkley | Linda Pittmon | John Wiggins | Swift River Request time Explained HIPPA protocol Fall, risk for Reassess pts VS in 3-5 minutes: BP 85/44, P 52, R 16 (pt intubated and vented by RT) Other Quizlet sets. Increase supplemental O2 Impaired home maintenance mgmg r/t client or family: False Evaluate understanding Provide education regarding HF Reassess pt Notify surgeon Educate Ms. Horton that paroxetine (Paxil) is to be taken as ordered Impaired comfort Assess I/O and possible reasoning He refuses to comply with dietary recommendations. Health Change - normal Establish large IV access Wash & glove 1-Listen to patient's concern Encourage first IS Remove infiltrated IV Initiate anti-psychotic meds Document Scenario #2 Perform hand hygiene and don gloves Prepare to initiate cardioversion. Assess VS elisabeth_hamilton. Hydrocodone 5 mg Acetaminophen 325 mg (Norco 5mg) 1-2 tablets every 3-4 hrs PRN moderated to severe pain #30. Scenario 3 Assess pt's concerns Check VS Scenario #3 - Health Change - increased Provide introductory information on prescribed antithrombotic medication. Connect telemetry Contact respiratory therapy -Notify HCP and nursing supervisor Risk for injury related to falls, Scenario #1 -Explain to Chaplain that you cannot discuss patients who are admitted or not admitted to the hospital You are now preparing for d/c. Deficient knowledge: True -Orient patient to bathroom with specifics Notify charge nurse His partner is not with him at this time but will arrive soon to facilitate his discharge home. Check NG tube placement Contact RT Psychological Needs: Normal acuity, Physiological - Escort pt. - Ineffective health maintenance Assess toe movement and cap refill Medicate pt. Call the HCP and provide the following information utilizing SBAR: Educational - Increased VS: BP 92/58, P 102, R 30 and labored, T 101.3, SaO2 91%. 3-Comfort and orient patient to person, place, and time. 4 Psychological abuse Discuss physical limitations follow a MI -Test patient's vision with number of fingers, objects, etc. Notify Dr if condition is abnormal Request CNA to remain w/ pt Call for code Evaluate understanding Health Change - increased - Physical mobility, impaired Explain procedure 5-Notify the Provider of the patient and family's inquiry on next steps Assist pt. Scenario 3 Scenario 1 Call for help Acute pain: True Introduce hospital liaison, Acute pain Don gloves Risk for injury: True, Scenario 1 -Provide emotional support for the patient`s husband. Full assessment Initiate IV Alteration of protective mechanisms: True. Pain - increased -Grief Set up sterile HCP orders 1.) Sensorium - normal, - Acute pain Inform the pt. Medicate w/ Demerol 100mg w/ Phenegran 25mg IM prior to dressing changes 5.) Sleep deprivation: False. Explain to daughter Assess last medication Scenario 5 Tell husband & pt. 37. Disturbed body: True Deficient knowledge Scenario 1 -Request assistance with your other patients and determine family's availability to stay with the patient - Sensorium - normal, - Chronic pain Educate pt Record I/O Reassess pt. Scenario #5 Assess pt's preferred Scenario #5 Scenario 2 Call HCP for change in health status and receive orders for anxiety medication Scenario #4 Ask PCT to secure mask better, and inform her that there is no replacement for her. Start O2 @ 2LNC Request the uncle participates Fall, Risk for: True Scenario 4 She was admitted yesterday for stabilization of her glucose levels and . Fear: False Scenario 4 Take VS Scenario 3 Recommend pt. Explain the procedure to Ms. Horton Notify infection control nurse DNR armband - Pain - increased Scenario 5 Impaired mobility, risk for Right after admission the nurse finds her walking down the hall trying to leave. He is now in V-tach w/ a weak pulse and BP 70/40. Describe the situation and what you did to deal with the situation. Scenario #4 Psychological Needs - normal Don clean gloves Started on Atenolol 50mg, 1x/day. Neurological - normal, Scenario #1 Constipation: False Reassess blood glucose Educate pt. -Apply dry sterile dressing to IV site Therapeutic communication Tell me where you are Change to simple O2 face mask per HCP Delay insertion of IV 7. As Ms. Horton is waiting by the exterior hospital door, construction workers are on the road working w/ a jackhammer. Scenario 5 This survey aimed to determine the frequency and symptoms of dysmenorrhea, as identified by differen. Assist pt out of bed Acute pain Administer rectal - Impaired skin integrity Perform neuro assess Neurological: Normal acuity The patient`s vital signs, are BP: 152/90, P: 101, R: 28, T: 99.1 F, 37.23, hyperglycemia. Fall Risk: Normal acuity Swift Water Awareness. Ask if the pt. Impaired mobility: True Start studying swift river med surg. Ask open-ended Ask pt. Kenny Barrett diagnosis of type II diabetes. She presses the call light w/ questions about who her RN will be and her NG-tube. Scenario #4 Educate pt. Evaluate understanding Complete initial Contact provider Wash hands prior to entering the room Scenario #3 Bleeding NG tube to LIS of the plan Place sterile moistened Request possible change in medication and more frequent VS checks Encourage fluids Risk for infection Contact dietary consult Scenario #3 Swift River- Community Health. Provide comfort Psychological Needs: Increased acuity, Educational Needs: Increased acuity Repeat 1mg atropine Evaluate pts understanding of medication and provide education Deficient knowledge The sister of Mr. Mancia calls from home to speak w/ you. BP 190/110, P 86. - Impaired tissue perfusion Scenario 2 Full assessment Upon assessment, you determined that she is confused to person, time, and place but is easily directable. Risk for physical injury: True 3-Direct Chaplain to the visitor desk Dysfunctional Gastrointestinal Motility: False Reassure patient of options Expert Answer. Notify doctor (for possible removal) Sensorium: Normal acuity, Physiological- Ms. Rails states that she has not had a bowel movement (BM) in the past two days. Remove old dressing w/ clean gloves daily allow expression of feelings Medicate Scenario #5 Document results, Educational Needs: Increased acuity Pain Level: Increased acuity Apply triple abx ointment to edges of wound each dressing change 3.) Document Start IV Start and IV Pt. Psychological Needs: Normal acuity Sleep deprivation: False Assess for fall Request possible change Estelle Hatcher List the nursing care order. Remind staff that Universal Precautions are practiced at this hospital for all pts regardless of known ID's. Scenario 2 Assess VS and perform head to toe assessment lay on their side, Acute pain Pt is complaining of pain in her shoulder and thigh 7/10 lOMoARcPSD|7327774 New Patients Swift river med . Scenario #3 Check blood glucose Perform dressing 3-Switch pulse ox to the right hand Document, - Educational Needs - increased Assess pain and rhythm Q15 minutes Reassess BP & P Provide operative summary of type of procedure, IV fluid and pain status. Nutrition Scenario #4 Discuss follow up with his doctor. Health Change - increased He has bilateral lower lobe atelectasis w/ bronchial vesicular wheezing. Call local law enforcement, Educational - increased Talk w/ her stating surgery is over and she did great -Notify the provider after stopping the infusion Educate pt as to why he cannot go outside and smoke Bleeding: False Contact hospital liaison Full assessment Notify HIPAA Complete neuro Administer pain meds - Psychological Needs - normal, - Disturbed body image Medicate What was the priority nursing assessment (s)?-Russel Montgomery- Spinal Injury: assess neuro, musculoskeletal, respiratory-Thomas Bechman- Gout & Dementia: assess integumentary, neuro, musculoskeletal, endocrine (for levothyroxine) -Louis Hutchinson- Amyotrophic lateral sclerosis (ALS): musculoskeletal, neurological, integumentary Evaluate learning Scenario #5 Disconnect NG tube Deficient knowledge Assess documented pain She pulled out her IV and it will need to be restarted for her IV I pro dose that is due now. LOC - normal (Blood to dialysis solution or dialysis solution to blood). 6 terms. After 24 hrs, Ms. Gestalt fever and chills have subsided but now states she is feeling like her cast is too tight Acute confusion Remind staff Scenario 1 Begin fluid and electrolyte Upon entering the room, it was noted that she appeared to be asleep, eyes closed, possibly experiencing a bad dream Secure dressing Reinforce need Neurological: Normal acuity Scenario 4 Swift River Dotty Hamilton scenarios; Swift River Jose Martinez scenarios; Blood Therapy lesson 2 post test; Blood Therapy Exam; HESI Case Study Sentinel Event Suicide; . Impaired comfort: True Release restraints/full range of motion Scenario #3 His partner is at the bedside asking, "How much longer will he have to wait until taken to surgery?" Call charge nurse Assess pt. Provide therapeutic Educate pt. Perform comfort Fall, risk for Assure pt. Infection, risk for, Scenario #1 -Obtain witnesses to sign an advance directive Use therapeutic Report current Scenario #5 2-Have the patient rest in the same position and repeat BP assessment in 15 minutes Scenario #3 Assess for contraindications Offer assistance Remove infiltrated IV Complete skin assessment Serum Sodium 142 mEq/L Use therapeutic Educate pt. Scenario #3 Scenario 3 Establish large IV Remove clean gloves, wash hands, put on sterile gloves Notify HCP Upon entering the room, you find Ms. Rails sleeping. Pain - increased Assess the injury Scenario 3 Scenario #4 Safety - increased Impaired skin integrity: True Sensorium: Normal acuity, Physiological- Check cranial nerves Several hours later, Mr. Duncan is now complaining of nausea. Fear: True Fall, Risk for: True Scenario #2 Your response to all of them would be: Scenario 1 Notify HCP Mr. Wright is pleasant and cooperative but needs to be reminded to avoid pressure on his heel and sacrum. Ethical issues for practice? joyce workman swiftriver Flashcards | Quizlet Don clean gloves to remove old dressing Impaired mobility, risk for Establish an IV Shock, risk for: False Neurological - normal, Chronic pain Swift River- Pediatrics. She is frustrated and overwhelmed with the new appliance not working properly. 5-Ask the patient and family member if there is anything, we can do to make her more comfortable condition Obtain surgical Health Change: Increased acuity Don PPE Present health assessment Give ASA Clean wound Apply NC O2 Scenario 1 Provide Morphine sulfate IVP as prescribed Family dynamics Consult wound care Report finding to HCP using SBAR. Obtain an order to insert a Foley catheter Joyce Workman, a 42-year-old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Use therapeutic communication/Active listening Assess pt's sputum Check leads - Psychological Needs - increased Administer Valium and legs. Psychological Needs - increased Take VS Document results Tell the pt. Explore new ways Assess family support system Hypothermia: False - Sensorium - normal, - Acute pain Scenario 1 Assess for bowel sounds - Safety - increased, - Pain, acute Ensure no one RBC Scenario 2 -Put tray on bedside table and align to a comfortable eating position Bleeding, risk for Gas exchange Scenario 4 Call HCP Do not disturb the pt Mary Barkley 3. Notify doctor Medicate She has sleep apnea, and she brought her CPAP machine. Assess Mr. Wright's willingness to learn. Assist w/ intubation and logistics of managing the critical pt on the floor. Neurological: Increased acuity Elevate stump, - Educational - increased Complete head-to-toe Notify the HCP of absence of Advanced Directive and the families request to intubate. Verify call light Scenario #2 Document, Educational - increased Remind CODE Assist w/ intubation, Educational - increased Construct dietary consult (plan) She has arrived at 0600 and is scheduled for a laparoscopic Roux-en-Y gastric bypass (RYGB). - Health Change - increased Health Change: Increased acuity Marcella is very worried about STD's and posssible pregnancy, Scenario 1 Scenario 4 Wash hands Wash and glove on 100% non-rebreather Upon entering the room, the pt is crying and asks when will the medication fix her heart. Ask the charge nurses to assign another nurse to the new admission. Pain - increased Alert Mr. Wright's case manager of concerns of home environment. Reassess VS and chest pain Safety Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Give Me Liberty! Use therapeutic communication/active listening Scenario 1 The, patient is not on O2. Administer prescribed Ramona Stukes Remove clean gloves Scenario 3 Scenario 5 Wash and glove hands -Introduce UAP and Mrs. Barkley to each other Document Hopelessness: False. Health Change: Increased acuity Tell the mother that you understand Notify charge RN Complete full assessment Safety- Document Scenario #1 Contact Wound Care directly Don Johnson - Concepts of Nursing III - Studocu q 5 min Perform circulatory evaluation Make sure O2 mask -Metabolism Contact HCP Infection, risk for: False Sit with the pt. Fall Risk - increased Fall Risk - increased Scenario #2 Peripheral neurovascular dysfunction: True. Ensure signed consent Macro Final - Quiz 4. - Health Change - increased Knowledge deficit: False Assess respiratory status by observation Preston Wright 10. Document conversation CBC, CMP, Blood culture x 2, Hgb A1C 3.) Wash handa Scenario 1 Anxiety: True Begin post-op Evaluate understanding Give verbal Tom Richardson Check the client Fall, risk for Acute Confusion True Scenario #4 Evaluate understanding Establish when the cardiac event time began Notify doctor Psychological Needs: Increased acuity, Physiological - Vital signs taken by automatic BP cuff q 15 min Call Mr. Jones's children Establish second Explain to Mr. and Mrs. Martinez the disease recess following a MI Ann Rails You are entering the room for the first time. Assess pt's pain -She experienced life threatening wounds with 2 gunshot wounds, including one to the shoulder Constipation, risk for: True Check pupils Schedule Cardiac rehab Apply O2 at 2LNC Restart new IV Psychological Needs: Increased acuity, Physiological- Initiate I&O Her last K was 3.2 mEq/L. Perform full assessment Proved additional teaching Scenario 1 Contact IV team Offer nutrition/toilet Evaluate pt. Offer nutrition and/or toileting Observe for bleeding Notify the social worker, Acute pain of need Assess IV Perform admission Medicate pt Reassure pt. Scenario #3 Scenario #1 Mrs. Smith's surgery has now ended. Give your answer as a percent and round to one decimal place when necessary: 27.4%81\frac{27.4 \%}{8 \cdot 1}8127.4%, (a) Calculate the osmotic pressure of the hemodialysis solution at 25C25^{\circ} \mathrm{C}25C. Redirect the pt back to her room. Review medication orders for pain Discuss support groups, Educational Needs: Increased acuity Encourage positioning Contact Assisted Living Facility to see if pt has an advanced directive in place declining intubation.
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