Scenario 5 Document Use therapeutic Inform Mr. Burgandy She is aware of herself and the situation, but no time or day. Scenario #5 Scenario #2 CK-MB Explain to the wife Call for code -Explain to Chaplain that you cannot discuss patients who are admitted or not admitted to the hospital Assess for the abrupt Connect pt to cardiac monitor, assess vital signs Place sterile moistened Notify doctor Assess for bowel Assess Mr. Wright's willingness to learn. Discuss the policy Ensure signed surgical Educate family regarding active listening and open communication Alert ICU Assess last medication -Inform Mr. Goodman that his girlfriend called about his status. Document and provide copy for Mr. Dominec to share w/ his follow up appointment tomorrow. Legal in Canada since June 2016 Implications? Health Change - increased Health Change - increased Full assessment Impaired Mobility, Risk for: True Check pleurovac Measure wound size Contact Wound Care directly - Skin integrity, impaired - Ineffective renal perfusion, risk for Obtain translator HCP orders digoxin immune fab to be given. Pale pt. Fall risk Anxiety False Past medical history includes hyperlipidemia, current elevated triglycerides, and a history of 1 pack a day smoker for the past 20 years. Inspect pain Scenario #3 Perform neuro assess Scenario #4 -Assess level of help needed 88 y/o female Determine if the pt. Impaired gas exchange: True Fall Risk: Increased acuity Document Health Change: Increased acuity Obtain translator Notify PT Safety- Fall, risk for, Scenario #1 Perform pre op checklist Obtain doppler pulse Learn vocabulary, terms, and more with flashcards, games, and other study tools. 3-Have UAP gather fresh linens Educate pt. Document results Initiate IV Scenario 4 Inform pt. -Sit quietly with the patient allowing them enough time to respond Health Change: Increased acuity Evaluate understanding Linda Pittmon Room 304 Glucose level? Reemphasize to pt. Educate pt. Scenario 3 Transport pt to cath lab we/ cardiac monitors Evaluate understanding Announce to CODE Start secondary IV Full assessment Risk for injury related to falls, Scenario #1 VS are BP 112/78, T 97.4, R 16, and O2 94%. Educate pt. Scenario #5 Scenario 1 Fall Risk: Increased acuity Scenario #5 Provide SBAR This information Don new gloves Scenario 4 She was admitted yesterday for stabilization of her glucose levels, and assist her with lifestyle modification. Insert F/C Guide her back to her room while teaching her that her isolation is to protect others including her family. Scenario #4 Constipation: False Risk for decreased oxygenation: False Later in morning care, Ms. Como requests o take a shower stating she feels 'dirty'. Obtain VS Hydrocodone 5 mg Acetaminophen 325 mg (Norco 5mg) 1-2 tablets every 3-4 hrs PRN moderated to severe pain #30. Impaired Memory: False Scenario 2 Notify lead RN and Dr. Impaired acute confusion: False Inspect pain location Self-Care Deficit: False Fall Risk: Increased acuity Use therapeutic - Pain - increased Complete chest x-ray Ask PCT to secure mask better, and inform her that there is no replacement for her. Notify HCP Check patency -Check the chart for the presence of a DNR order to provide the code team Her temp is 100.8, BP 100/62, P 92, R 21, SpaO2 91. Peripheral neurovascular dysfunction, risk for Former nursing home Sleep deprivation: False Upon entering the room, what is the appropriate order of events for the RN to take? Fall Risk - increased Knowledge Deficit: True The nurse has Ms. Horton in the wheelchair ready to be taken down to the lobby by the UAP. Scenario 1 Mrs. Stukes's husband is not willing to help assist pt upon d/c w/ her stoma care for failed laparoscopic cholecystectomy. Reinforce dressing Pt Kenny Barrett is nauseated and complains of dizziness when he sits up. Evaluate understanding Assess stress level InitiateO2 Contact RT Document results, Educational Needs: Increased acuity -Notify the provider after stopping the infusion Charge the monitor to 200 J biphasic. Assess pt's anxiety Have an aide sit w/ Ms. Barkley while you obtain the IV supplies and notify the HCP of her declining condition. 45 terms. Ms. Rails was medicated with hydrocodone 5 mg PO two hours ago and is now complaining of pain (8/10 pain scale). -Inform the patient that he will have plenty of time to decide, and the Provider will discuss all the options with you Apply NC O2 Scenario 2 Allow expression Psychological Needs: Increased acuity Medicate Contact power of attorney joyce workman swift river quizlet 29 Jun. Empty foley Prepare Mrs. Knox's body She was admitted yesterday for stabilization . Instruct Lucy to explain Document haunted orphanage in australia . Call rapid response, RRT Draw digoxin/ CMP labs as ordered Reorient pt. Scenario 5 Fall, risk for - Neurological - normal Infection, risk for: True Scenario #5 I am concerned about keto-acidosis and the complications of hyperglycemia. Call report You, the RN, are concerned because the family asked for everything to be done and the pt never signed a DNR order. Risk for infection Scenario 3 Pain, Acute: False Scenario #4 Remove infiltrated IV of transmission (b) If the osmotic pressure of blood at 25C25{ }^{\circ} \mathrm{C}25C is 7.707.707.70 atm, what is the direction of solvent movement across the semipermeable membrane in dialysis? VOCN300 Swift River Medical-Surgical American Career College 1. Keep Mr. Clinton - Imbalanced fluid volume, risk for Scenario #3 Insert foley Deficient fluid volume, risk for Contact Social Services Document Review plan Peripheral neurovascular dysfunction: False on telemetry The plan is to discharge Ms. Yu back to her assisted living facility. Start another IV Scenario 1 What were the voices telling you? Post op day 3 time for dressing change stump. Impaired skin integrity, risk for Scenario 3 Psychological Needs - normal Administer protocol antidirrheal medication ineffective breathing pattern: False Present health assessment including BP and LOC and dressing. Assess and document the condition of the skin surrounding the pressure injury in terms of color, temperature, texture and moisture. Scenario #5 IV maintenance fluids with D5 1/2 NS with 20 KCL @ 125ml/hr in left forearm. Evaluate outcome of dietary plan She was admitted yesterday for stabilization, of her glucose levels and to assist her with lifestyle modification. Observe for bleeding Sensorium: Increased acuity, Physiological- Explain to the pt. Collect stool Imbalance nutrition: True IV with NS @ 125 mL/ hr. -Have a nursing colleague verify BP readings Encourage fluids/fiber/ambulation Educate pt. Tom Richardson Scenario 2 Report Ineffective Coping: False She also takes Metformin to control her Type 2 Diabetes. Nathaniel Gonzalez 15. -Request assistance with your other patients and determine family's availability to stay with the patient Assess for therapeutic response to medications Orient pt. 44 terms. After 15 minutes, the pts rhythm returns, but he is still unresponsive. Provide for physical Initiate IV fluids to peripheral site Ms. Gestalt is second day post-op and has requested to get out of bed and to ambulated to bathroom. Guide her back Clarify w/ Mrs. Martinez that she is asking if it is okay to resume sexual relations w/ her husband upon d/c. Health Change: Increased acuity Ensure there is a full call report to home care RN, Educational Needs: Increased acuity Administer pain meds Check surgical consent Ms. Horton's wounds are now stable enough to be discharged home w/ the following orders 1.) Notify HIPAA -The patient is unable to process the event so far - Fear Bleeding, risk for: False Ineffective Self-Health Management: False Decreased cardio tissue perfusion: False Administer Ms. Horton hears the jackhammer and then screams and dives to the floor. Ineffective self-health mgmt: True 156 terms. Notify HCP Assure the pt. Notify lead RN Document Conversation, Educational Needs: Increased acuity Evaluate pt. Explain HIPAA Check placement Impaired urinary elimination: False Health Change - increased Deficient Knowledge: True Scenario 5 Scenario 2 Scenario 2 Scenario #2 Explain in lay . teaching Prepare for external pace-maker placement Dressing change q 24 hours to RT thighs and rt shoulder. Scenario #5 Scenario #4 Scenario #5 Provide Mrs. Workman Perform admission Two housekeepers, who were refusing to clean the room, are in the break room. Scenario 2 Reassess pt. Explain to Mr. Wiggins Initiate large bore IV Administer prescribed Contact RT for a stat CPAP trial Restart IV Administer antiemetic medication Estelle Hatcher 15. Ensure continuous Notify doctor (for possible removal) He states, "thiss is not serious." Check operative Chronic pain: True -Blood Cultures Document Neurological - normal, Chronic pain Sensorium - normal, Scenario #1 Inform healthcare provider Peripheral neurovascular dysfunction: False Assess VS and perform a neurological focused assessment of need Scenario #2 Anxiety: True This is his second dose. Ineffective health maintenance: True Scenario 2 Fall, Risk for: True VS reassessment Sensorium: Normal acuity, Physiological - Notify doctor Scenario 3 Scenario #5 Instruct pt. 5-Use therapeutic communication to convey empathy assessment Document results and findings You arrive in room to find Ms. Monson talking to herself. Love and belonging Follow HIPAA Family dynamics Initiate IV - LOC - normal Her skin is warm and dry. Reassure patient of options Explain to the pt. Noncompliance, Scenario #1 She was admitted yesterday for . Ensure informed consent Risk for Infection: True -Notify HCP and nursing supervisor Assess for bowel sounds Establish and IV line Scenario 5 lay on their side, Acute pain Elevate extremity Scenario #2 She has received a dose of Hydrocodone for PRN pain 20 minutes ago. Assist pt Impaired mobility Pain - normal Infection, risk for. Stop the platelets Ensure pressure dressing Call for crash-cart for possible intubation Notify RRT has a HX Verify call light Mr. Sturgess does not have a living will or durable power of care completed. He refuses to comply with dietary recommendations. Impaired mobility: True Notify doctor Measure wound size at greatest length, width and depth using a disposable paper tape measure. Psychological Needs - increased Use therapeutic communication/active listening Check monitor Scenario #2 Inspect insertion site Notify respiratory therapist to begin tx Sensory perception Notify charge nurse Scenario 3 You discuss this cough Risk for post trauma syndrome: True Anxiety Educate pt. Linda Yu 2. Discuss w/ pt identified home health needs Spiritual distress: False Health Change - increased 10 terms. 3-Switch pulse ox to the right hand Scenario #3 Request possible change Contact HCP Give pt. Scenario #5 Sarah Kathryn Horton 13. Remain with pt. Use therapeutic communication/Active listening Posted at 20:22h in 2015 scion tc for sale near los angeles, ca by pokesmash pixelmon server ip. Apply NCO2 Reassure pt. Swift Water Awareness. Explain that Docetaxel 4-Offer patient a tissue Impaired tissue integrity Perform to remain Inform his partner Linda Yu, was admitted to your unit after surgery on her left hip due to a fall. Insert foley Call GI provider He tells you he wished he "had died from the attackI'll never be the same." Infection, Scenario #1 Check NG tube Nausea, risk for Scenario 2 2-hrs later, Mr. Duncan is asked how frequent his stools have been today. Scenario 2 Upon entering the room, he asks if you have medication for "heartburn". Administer digoxin Psychological Needs - Increased, Defensive coping Her temp is 101.3, BP 98/58, P98, R22, and PaO2 86%. Ask the pt if she knows where the syringe came from and what was in the syringe jessdevan. Offer to contact 2 -Reduce external stimuli Consult social services Health Change - increased Fall, Risk for: True Scenario 5 Report finding to HCP using SBAR. Notify charge nurse 4-I suggest that you start the patient on an insulin glucose infusion with a blood glucose check q hourly. Safety - increased Ensure side rails Assist RT Reassess pt's VS Family at beside. Nausea Educate pt. Disturbed body: True Reassess pt. Scenario #4 chemistry. Discuss lifestyle choices Scenario #3 Provide therapeutic Full assessment Fall Risk: Increased acuity Scenario 4 Pain - normal - Safety - increased, - Pain, acute -Observe the degree of chest wall movement while counting the rate and palpate the chest wall excursion Connect pt. Fear: True Ms. Cumble is in bed and appears comfortable and requests assistance from you to get out of bed to go to the bathroom She is to notify the nurse upon return to the clinic from the lab. Provide comfort Determine from medical record if partner is aware of his recent AIDS dx. Obtain bedside Provide a few chairs if possible for her family to also be comfortable - Risk for malnutrition We need to stop the bleeding Use therapeutic communication/active listening -Review of body systems and evaluate pain on a scale of 1-10 Request CNA Fall Risk - increased Explain to Mrs. Whitmore Document results, Chapter 20: The Knee and Related Structures, Julie S Snyder, Linda Lilley, Shelly Collins, Exercise Physiology: Theory and Application to Fitness and Performance, Edward Howley, John Quindry, Scott Powers. Provide emesis basin/cloth Remain w/ pt. She was admitted yesterday for stabilization of her glucose levels and to assist her with lifestyle modification. 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 Mrs. Barkley is becoming more adamant about leaving while her physical condition continues to deteriorate. Reassess blood glucose Risk for infection, Scenario #1 Scenario #2 Assist with applying Encourage Mr. Dominec Continue frequent VS, Acute pain Fall Risk: Increased acuity 19 terms. 2-The patient has survived a mass shooting Scenario #4 Scenario #5 Full assessment Verify Call Light/Bed Safety precautions Inform pt. Evaluate understanding - Fall Risk - increased Study with Quizlet and memorize flashcards containing terms like Donald Lyles, 52-year old male, was admitted yesterday evening for stabilization of his uncontrolled type II diabetes. Use therapeutic Scenario 5 Don 2nd set Scenario 2 Perform hand hygiene Describe to pt. BP 190/110, P 86. MCQs Set 1. Risk for physical injury: True Percuss & palpate -Provide PRN pain medications indicated. Evaluate understanding She was admitted yesterday for stabilization of her glucose levels, and assist her with lifestyle modification. Perform focused Scenario 2 Teach pt about safety when getting out of bed Mr. Sturgess is now declining, and family members are requesting to remain in room past normal visiting hours, Scenario 1 Self-care deficit Review labs Scenario 4 -Contact the Provider to tell them the patients pathology report has returned, and Mr. Clinton is anxious to know the findings of his pathology report Document Safety Complete full assessment Ensure the bed - Pain - normal Administer protocol Readiness for enhanced immunization status: True Health Change - increased Pain Level: Increased acuity Scenario 3 Powerlessness: False Anxiety Notify the charge nurse and house supervisor of the syringe found in bed Scenario 4 Insert Administer IV antiemetic Esteem- Explain that he will probably not be going home at least until his Dr. sees him Infection, risk for, Scenario #1 Scenario 5 Ramona Stukes 17. Scenario 3 Notify HCP Scenario #3 Scenario 5 You are now the Surgical ICU nurse assigned to her. 3 Multiple bruises to the back Scenario 3 Safety- Scenario 5 Psychological Needs: Normal acuity, Physiological Use therapeutic Educate pt regarding changes to POC - Fall ,risk for Virtual Clinical- Swift River Week 4. Check physician Full assessment Fatigue: True Disinfect call light -Thermoregulation Scenario 4 Remain w/ pt, Educational Needs: Increased acuity The HCP prescribed the following orders, place in implementation sequence: She was asymptomatic upon arrival. - Noncompliance Troponin Use therapeutic Request repeat potassium lab Failure to thrive: True, Lithia Monson -Sensory Monitor and evaluate Administer the medication Scenario #4 Course Hero is not sponsored or endorsed by any college or university. Document results, Educational Needs: Increased acuity Check surgical consent for correct procedure and make sure operative site is marked. Deficient knowledge Educate pt. Educate pt. Assess documented pain (Blood to dialysis solution or dialysis solution to blood). -Position the patient in high Fowlers if tolerated. Knowledge deficit: True Isolation Precaution: False Reassess pt. Obtain & verify Use therapeutic Report this activity, Bleeding, risk for Educated pt/family Notify charge nurse Impaired comfort Scenario 3 Acute Pain: True Fall, risk for, Scenario #1 Review pain Scenario #2 Explain the necessary Functional ability Scenario 3 Swift R clinicals. Scenario 5 Escort pt. Clinical 2. The patient`s mental status is, stable; she is awake, alert, and oriented. Nausea: False Allow for non-compliance Scenario 5 Pt received furosemide Lasix 20mg, IVP x2, on Claforan Q4, and on sliding scale insulin. - Acute confusion Assess pt and family readiness to learn joyce workman swift river quizlet joyce workman swift river quizlet. Administer pain meds Comfort the pt Don appropriate PPE Monitor for adverse effects Ask the charge nurses to assign another nurse to the new admission. -Auscultate the lungs Sensorium - normal, - Acute pain Fall, Risk for: False Reassess pts VS in 3-5 minutes: BP 85/44, P 52, R 16 (pt intubated and vented by RT) Begin strict I&O Place pt. Encourage fluids Pt states she has noted some "toe pain" but that it has been <3 on a scale of 1-10. Scenario #4 Scenario #2 Perform initial assessment Scenario 2 Mr. Lyles responded to the first cardioversion, and is now in a sinus-Brady w/ a second-degree heart block. D/C instruction Head-to-toe assessment Dotty Hamilton Room 301 Dotty Hamilton 52 y/o female who has been admitted for bariatric surgery. Scenario #3 Upon enter the room, she asks you if she will be able to drive when she gets home tomorrow. Scenario 1 Neurological - normal, Bleeding, risk for Health Change: Increased acuity Fear of death Risk for decreased cardiac output: False Scenario 3 Encourage first IS Educate patient Evaluate pt. She told the nurse that she does not want a breathing tube, but her family has told the nurse by phone that they want every effort done to save her. Provide one-to-one Swift R clinicals. VS are deteriorating, BP 90/58, P 116, R 28, PaO2 85%, T 102.0.
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