Scenario #2 2.) Seek clarification Scenario 1 Record I/O What should be included in the A. Fall Risk - normal Inspect pain Full assessment Perform hand hygiene - Failure to thrive, Scenario #1 Scenario 2 to explain - Impaired tissue perfusion Explain the TX Scenario #3 He is anxious that he will forget to take it or take the wrong dose. Upon entering the pts room, he is threatening to go outside and smoke, agitated and demanding to be d/c'd to have a cigarette. Asminister morphine He replies," six times in the past four hours". Place steps in order. Neurological: Normal acuity NrsSR22. 4-Place 100% non-rebreather on the patient Psychological Needs - increased Psychological Needs - increased Social isolation, Scenario #1 Administer prescribed - Deficient knowledge You arrive in room to find Ms. Monson talking to herself. Initiate IV Sensorium - normal, Acute Pain Therapeutic Communication Scenario 5 2 -Reduce external stimuli Ineffective self-health management: False -Consider warming the patient's hands to get an accurate reading Compromised family coping: False Suggest Surgery called to the unit the Ms. Pittman is scheduled at 1300 for a BKA. Estelle Hatcher 15. Reassure pt. Guide her back Health Change: Increased acuity Assist RRT Disturbed body image: True 4-Contact Provider for an anxiolytic medication Safety: Increased acuity, Physiological- Estelle Hatcher, 31yr-old, r/o appendicitis, 1st day post-op appendectomy; No known allergies (NKA); Vital signs - Temp 101.2, BP 108/74, P 92, RR 20, SaO2 99%, alert and cooperative. -Explain HIPAA policy to the girlfriend Provide Morphine sulfate IVP as prescribed Scenario 2 Scenario #1 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. Full assessment Perform initial assessment -Check for color perception The HCP is requesting an update on sacral wound healing. - Noncompliance joyce workman swift river quizlet joyce workman swift river quizlet. Place pt. Ensure family member Ensure IV access Medicate pt Risk for injury at home, Scenario #1 Neurological - increased, Acute pain Complete bed bath Scenario 5 Scenario #5 -Grief Discuss lifestyle choices Reassess effectiveness Joyce Workman, a 42-year-old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Sensorium: Normal acuity, Physiological- Scenario #3 Take VS Pain Level: Normal acuity Check NG tube Assess for pain - Acute confusion 7. Reassess environment Label the sporophyte plant stages of the life cycle. Inspect pt's abdomen Preston Wright, 73-year-old male patient of Dr. Greene, status post CVA 4 weeks ago. Do not probe A group of university students conduct a survey regarding menstrual pain for their biology subject. Promote open communication between mr. and Mrs. Martinez Stop marking it as incomplete or missing info! Provide Mrs. Workman Psychological Needs - normal Make referral Safety- Weight the pt. - Deficient knowledge Disconnect NG tube Mr. Martinez was taken emergently to the cath-lab and had 3 stents inserted in his heart. CPK Assess insertion site Take vitals Scenario #5 & wife Love and belonging Obtain blood for lab testing and blood culture #2 He has been informed that for the next 18 months he should take antithrombotic therapy daily. Contact family Reassess VS & elevate HOB Scenario #2 Safety- Assess for therapeutic Scenario #5 -Request a volutrol/metered indwelling urinary catheter bag when they return form the OR. Health Change: Increased acuity ID pt Impaired home maintenance management: False Assess pt. Ms. Hatcher is second day post-op and has a NG tube set to gravity drainage only. Impaired tissue perfusion: True Perfusion, risk for Remain with patient Assess pt's pain Scenario #4 Scenario 2 Educate pt Psychological Needs - increased Scenario #3 Scenario 5 Ask pt. Assess for the abrupt The nurse has another high acuity admission that has just arrived from the ER. -The patient is unable to process the event so far Validate NPO status Health Change - increased She has well controlled hypertension with Losartan (Cozaar) 50 mg q daily. Ensure pt. -Explain to Mrs. Barkley that you are going to change her linens Inform the pt. Instruct pt. Obtain blood (culture #2) Scenario #3 Deficient knowledge - Drug therapy, Scenario #1 Reassess pt. The indicator HIn has an acid dissociation constant of 4.80 \times 10^ {-6} 4.80106 at ordinary temperatures. - Physical mobility, impaired Psychological Needs: Increased acuity, Physiological - Check blood glucose Ask pt to explain to you what procedure she was expecting to have this morning. Educational - increased Rank as most concerning for labs Assist Mr. Jones Psychological Needs - increased Health Change: Increased acuity Evaluate pt's understanding Educate caller Esteem- Full assessment of pt Readiness for enhanced immunization status Deficient knowledge Call rapid response Recommend pt be txf to ICU Pt. Provide a few chairs Pain Level: Increased acuity Auscultate lungs Evaluate understanding Psychological Needs: Normal acuity, Physiological- Apply NCO2 Scenario 4 Repeat neuro Reinforce the risk Contact head RN Fall, risk for You observe Ms. Getts being assisted by another nurse who is being blatantly rude and disrespectful to her. Provide therapeutic Impaired mobility Fall - increased - Ineffective renal perfusion, risk for 4 Psychological abuse Request the uncle participates Health Change: Increased acuity Joyce Workman, Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Assess stress level Notify the physican of assessment findings and await further orders Inform his partner that everything is being done to keep him comfortable. Psychological Needs: Normal acuity Assist w/ intubation, Educational - increased Scenario #5 Alert Mr. Wright's case manager arrival Acute confusion Provide pt. It is now the second day post op and his is given discharge information. Don appropriate PPE Wash and glove Evaluate outcome of dietary plan on continuous pulse ox Scenario 2 She states she leads a sedentary lifestyle as a bank officer. -Ask the patient if she has reviewed her advance directive recently. Safety- Perform dressing The labs return w/ digoxin level of 10.5 ng/mL, K 5.3 mEq/L. Educate pt. Report and document results Start O2 Reassess VS & obtain UA Contact HCP Collect pre-op labs Scenario 2 Scenario 3 Request sitter Scenario 3 Sterile NS wet-to-dry dressing changes daily 2.) Take pt's family Notify charge nurse Document responses. -Metabolism - Powerlessness Medicate for pain Both RN have donned appropriate PPE and have entered the room. Document Safety- Imbalance nutrition: True -Administer the hydromorphone hydrochloride Change to simple -Assess peripheral vision com is the web's best . Safety- Page surgeon STAT Scenario #2 education Assist RT Assist RT to initiate CPAP trial Three days after d/c, you receive a phone call from Mrs. Stuke's neighbor, who is helping take care of her. Administer medication OOB Contact HCP Mrs. Stukes is a failed laparoscopic cholecystectomy that resulted in a bowel resection with a temporary ileostomy in place. Pulses above the stump are palpable at 2+, skin is warm and dry. VS & head-to-toe Scenario #3 Assess understanding through teach back Evaluate/modify plan of care She has been documented as being obese, new onset hypertension, polyuria, and a rash on her abdomen. Document teaching moment, Educational Needs: Increased acuity ID pt. Apply clean gloves Administer antipyretic Neurological - normal, Scenario #1 Provide comfort measures Discuss lifestyle changes Ms. Cumble is in bed and appears comfortable and requests assistance from you to get out of bed to go to the bathroom During the follow up nursing assessment, Ms. Hatcher complains about the NG-tube causing her pain in her nasal area. Document You are now preparing for d/c. Scenario 4 Request order for telemetry Educate pt. Document results and findings Reassess pt's VS's and pain level Have pt put on a mask -Provide emotional support for the patient`s husband. Health Change: Increased acuity After washing and gloving hands, you then identify yourself and the patient, Ann Rails. Scenario #4 - Ineffective airway clearance Ask pt. Impaired comfort When help arrives, pass off chest compressions and begin respiration's Obtain labs Talk w/ her stating surgery is over and she did great Encourage fluids Impaired physical mobility Don clean gloves A few days later, you are assigned to the same pt. 2 terms. Request possible change in medication and more frequent VS checks She was asymptomatic upon arrival. Scenario #5 1-I am calling about Joyce Workman. Explain to surgeon - Psychological Needs - increased, - Acute pain Disinfect call light Gather supplies needed for dressing change You return to the pts room 20 minutes later and the pt is pale, lying in bed, feels lightheaded and nauseated when he sits up. Impaired comfort Scenario 5 Ask if the pt understands the procedures scheduled for this AM Observe for bleeding Educate pt. Administer condition Notify social services Ensure cardio pads Hand hygiene The next day, he tests positive for COVID-19 and his condition has deteriorated as he is now in respiratory distress. Place call light and check bed for safety Peripheral neurovascualr dysfunction: False, Viola Cumble Use therapeutic Ask pt. Scenario 4 Pt is complaining of pain in her shoulder and thigh 7/10 Anxiety: True 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. Document, Educational - increased Vitals? -IV Antibiotics Noncompliance, Scenario #1 Assess Ms. Horton's Document findings/results, Physiological- Assess I/O and possible reasoning Review labs Ask parents 3 Multiple bruises to the back Two housekeepers, who were refusing to clean the room, are in the break room. Safety- Using therapeutic Ms. Gestalt is second day post-op and has requested to get out of bed and to ambulated to bathroom. Esteem: False Establish when the cardiac event time began Wash/glove hands Administer pain medications Assess VS Swift River Joyce Workman Room 304. Re-apply new sterile dressing. Inform pt. Explain to pt. Initiate IV Heparin Report Offer to contact Reassess VS Inform admitting physician They were also concerned about the next pt going into that room and the use of the lavatory. Ensure type and cross Infection, risk for, Scenario#1 Ask Mrs. Whitmore Scenario #2 Contact isolation Encourage aggressive IS She has been documented as being obese, new onset hypertension, polyuria, and a rash on her abdomen. Use therapeutic The CODE-blue team arrives w/ a crash cart, Physician, anesthetist, and 2 critical-care nurses and 1 respiratory therapist. Psychological Needs - increased Complete neuro Scenario 1 Nutrition Ms. Getts is being transferred as an emergency to Critical Care. Dr. Brown gives orders to remove NG-tube set to gravity and to begin a clear liquid diet change diet to HH 6.) Scenario 5 Psychological Needs: Normal acuity Employ therapeutic communication: present reality Sulfamethoxazole 800mg, Trimethoprim 160mg (Bactria DS) 1 tablet PO daily for 10 days 5.) Mr. Richardson is requesting assistance to ambulated to bathroom Impaired Communication: False Explain that he will Current VS BP 110/70, P 94, pt is pale, dizzy and nauseated. Escort pt to vehicle Assess pain and rhythm Q15 minutes Scenario #5 Diet plan? Be honest with Cameron Review current Reorient pt. Check I/O for possible dehydration Insert foley Document Call rapid response Contact HCP, Educational - increased Pain - normal on 100% O2 Educate caller regarding HIPAA Scenario 5 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. Scenario #2 Scenario 4 Assess family support system Contact Assisted Living Facility to see if pt has an advanced directive in place declining intubation. Other Quizlet sets. Carlos Mancia 11. Pt. Tissue integrity -Auscultate the lungs Scenario 3 Decisional conflict: True - Impaired gas exchange Alert the charge nurse that Ms. Barkley is deteriorating and you need to remain with her. View VCBC Glucose Regulation Swift River.docx from NURSING 246 at Colorado Christian University. Teach pt. Notify HCP 3-Notify the physician that the patient may be suffering from alcohol withdrawal. Joyce Workman Room 302 Joyce Workman, a 42-year-old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Scenario 1 Document Restart IV Fall, risk for -Assess radial and apical pulse for 60 seconds Vital signs taken Explain the need Apply restraint Educate pt Elevate HOB -Obtain witnesses to sign an advance directive Fluid & electrolyte imbalance, risk for Functional ability ECG was unremarkable. Mr. Raymond continues to deteriorate and becomes confused. Assist the pt back to bed Document Conversation, Educational Needs: Increased acuity Report suspicion of abuse to adult protective services Describe the situation and what you did to deal with the situation. Provide one-to-one Verify soft, low sodium Pain - increased Pain - normal Consult social services Scenario #3 Gas exchange, risk for Reassess pt. Ineffective health maintenance: True Notify charge nurse Disturbed personal identity: True Have IV ABX Initiate IV heparin Non-significant past medical history. Impaired gas exchange: True Disturbed sleep pattern: False Review with Mrs. Workman Other labs were WNL.
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