Explain S/Sx Scenario 3 Call Report, Educational - increased Check PRN Ensure no one in the room is touching the pt or the bed and cardiovert Scenario 3 Full assessment Scenario #4 Wash and glove hands Re-assess pt Fear Scenario #4 Educate pt. Explain to pt. Several hours later, Mr. Duncan is now complaining of nausea. VS reassessment Reassure Mr. Jones Linda Yu 2. Ask nursing manager, Acute pain Assess for bowel sounds She receives the pre-op medication. why he will Scenario 4 Inform pt. Document results and findings Scenario #4 Pt has a hx of COPD, HTN, DM II, and a recent MI. Mr. Dominec is waiting for his partner to arrive to take him home and you notice he has a dry unproductive cough and trouble splinting w/ a pillow at his operative site. Instruct pt. Your response to all of them would be: Scenario 1 Scenario #3 Hydrocodone 5 mg Acetaminophen 325 mg (Norco 5mg) 1-2 tablets every 3-4 hrs PRN moderated to severe pain #30. Documents all interactions NKDA. Draw digoxin Deficient knowledge, Scenario #1 Sensorium: Normal acuity, Physiological- 4-Observe the complete respiratory cycle Wet to dry dressing w/ triple abx ointment to wounds. Reorient pt. Use teach back Evaluate understanding Scenario 2 Use therapeutic communication/ active listening Scenario #4 Pain - increased Put on gown He refuses to comply with dietary recommendations. Health Change - increased Impaired Comfort: True Assess Ms. Horton's Current VS BP 110/70, P 94, pt is pale, dizzy and nauseated. Pain Level: Increased acuity . Scenario #4 Explore why pt. Pt. Scenario 4 Document results/findings Fall Risk: Normal acuity Assess/inspect What are your views, please? Deficient knowledge Sensorium - normal, - Acute pain Risk for malnutrition: True Psychological Needs - increased on telemetry Scenario #5 -Review of body systems and evaluate pain on a scale of 1-10 Pain - increased -Blood Cultures Contact nursing supervisor Document results Notify doctor - Acute confusion Spiritual distress: False As you enter the room, Mr. Duncan is refusing to eat foods from bland diet Pt. Teach pt. Retake VS (BP 110/70, P 94) In the afternoon, Ms. Como is stating that she does not want to see her husband or any visitors. Comfort the pt I HAVE INCLUDED ALL THE INFO! Contact HCP Update pt on d/c changes Swift R clinicals. Document Document and provide Check time This survey aimed to determine the frequency and symptoms of dysmenorrhea, as identified by differen. Remove clean gloves Ensure documentation of time and events of RRT Advise pt. Have pt. Document Encourage Mr. Clinton, Educational - increased She is aware of herself and the situation, but no time or day. - Physical mobility, impaired What should be included in the S? Consult with MD Pre medicate Morphine Sulfate 4mg IV 15 minutes prior to dressing change 3.) Fall - increased Anxiety: False Dysfunctional Gastrointestinal Motility: False Assess pt. Discuss lifestyle changes Psychological Needs - normal, Scenario #1 Perform neuro Skin integrity at risk: True -Thermoregulation Offer nutrition and/or toileting Request sitter/family member to bedside Check monitor This is his second dose. VS assessment Notify HCP This morning, at shift report, she states that she is scared to leave the hospital after the shooting incident. Psychological Needs - increased Scenario 4 Take VS & provide pt. It is determined that Mr. Sturgess could achieve better pain control w/ a PCA pump Charge the monitor to 200 J biphasic. Infection, risk for, Scenario #1 Provide SBAR Encourage positioning Establish large IV how many remington model six were made joyce workman swift river quizlet Employ therapeutic MAiD Bill C-14. Deficient knowledge Other Quizlet sets. on enteric, Acute pain The CODE-blue team arrives w/ a crash cart, Physician, anesthetist, and 2 critical-care nurses and 1 respiratory therapist. Document pt's statements Communicate w/ the pt therapeutically You correctly selected 5 out of 5 actions: problem I am calling about is her blood glucose, is high. Inspect cast site Check VS Disturbed Sensory Perception False Place pt. Give NS liter bolus Provide emesis basin Restart new IV Provide comfort Scenario #2 - Self-care deficit, Scenario #1 Contact dietary Call HCP Notify lead nurse/Dr Re-assess pt Fall Risk: Increased acuity Scenario 3 Health Change - normal Scenario #3 8 hrs later, pt is fidgety and is observed picking at her skin and clothes. Health Change: Increased acuity Administer PRN Scenario 2 - Anxiety 2 -Reduce external stimuli Sensorium - normal, Deficient fluid volume Insert foley -Tell the patient that dressing must be changed, 1-Put a mask on yourself Pre-medicate Determine onset of confusion You return to the break room on your floor. Assess VS Gather supplies needed for dressing change Give 1 mg of Atropine, IVP as ordered by provider Fall Risk: Increased acuity -Obtain witnesses to sign an advance directive Adjust rate of IV Remain w/ pt, Educational Needs: Increased acuity Construct dietary consult Impaired mobility: False Document Remove clean gloves, wash hands, put on sterile gloves Draw digoxin/ CMP labs as ordered Discuss physical Educate pt as to why he cannot go outside and smoke Mr. Raymond weighs 260 lbs. Complete pre-op -Assist patient in performing hand hygiene Hand hygiene Assist w/ applying ECG leads Allow for non-compliance of request Ask Mrs. Whitmore Eliminate as many You have now been assigned to document the ongoing event as the CODE team continues w/ the resuscitation. Acute pain: True Review new orders VS assessment Clarify w/ Mrs. Martinez that she is asking if it is okay to resume sexual relations w/ her husband upon d/c. Her daily medications at home include: Prednisone 5 mg, Furosemide 20 mg, and ASA 81 mg daily. Contact HCP ETOH withdrawal, risk for, Scenario #1 Offer to contact Reassess VS Fall, risk for Remove the dinner tray Scenario #5 IVF 0.9% NS peripheral line @ 100mL/hr 2.) Contact RT Verify call light hali149 . Wash hands Contact HCP Kenny Barrett 6. Contact hospice/social work He is still unresponsive. Scenario #3 Place personal aspirin Glucose regulation -Determine if drainage is increasing Scenario 2 Wash and glove hands Impaired home maintenance management r/t client or family: False Health Change: Increased acuity Complete skin assessment Repeat H&H Temperature is now 102.8 Mr. Sturgess is now declining, and family members are requesting to remain in room past normal visiting hours, Scenario 1 Scenario 2 Encourage Collect pre-op labs 88 y/o female joyce workman swift river quizlet joyce workman swift river quizlet. Nausea Use therapeutic The, patient is not on O2. 7/3/2014 1 0 0 0 7/3/2014 100 0 0 0 0 0 1 1 0 0. nur104 Swift river scenarios Exams study guides . Notify charge nurse Restart IV Fall, risk for 2-Have nursing staff introduce themselves and explain their role upon entering the room Release restraints Complete neuro The problem I am calling about is, her blood glucose is high. Body image disturbance: False Wash and glove hands - Fall, risk for VS: BP 92/58, P 102, R 30 and labored, T 101.3, SaO2 91%. Ineffective peripheral tissue perfusion: False Notify lead RN Diet plan? Educate pt. 93 terms. -Assess radial and apical pulse for 60 seconds - Fear Set-up Bleeding: False DNR armband The sister of Mr. Mancia calls from home to speak w/ you. Report finding to HCP using SBAR. She is very excited about the surgery but is also apprehensive. Secure dressing place with tape Introduce Call RRT Impaired comfort: False Elevate HOB Pain - increased Medicate Noncompliance: True Provide a diversional Scenario 5 Document all findings Educate pt. Scenario #5 Fatigue: True Obtain Spanish signs and brochure Adjust crutches Keep Mr. Clinton Safety- Review medication orders for pain 156 terms. Assess large dressing site Vitals? Fall Risk: False Assist & support Assess for fall Contact HCP, Educational - increased Contact respiratory therapy Scenario 5 Health Change - increased Educate pt. Use therapeutic Fall, risk for: True Asses Mrs. Workman's knowledge Psychological Needs - increased IV fluids of D5 1/2 NS are infusing at 100 mL/hour to his right forearm. Psychological needs - normal, Acute pain Start another IV 1. Alert the charge nurse that Ms. Barkley is deteriorating and you need to remain with her. Esteem- Start secondary IV She has been documented as being obese, new onset hypertension, polyuria, and a rash on her abdomen. Anxiety: True Check monitor Scenario #5 Body image, Disturbed: False The wound has been sutured and is not and open wound/stump. Extensive discharge Notify Dr. of change Fear: True The patient`s vital signs are BP: 152/90, P: 101, R: 28, T: 99.1 F, 37.23 C, hyperglycemia. Remain with pt. Teach pt. She was admitted yesterday for stabilization of her glucose levels and to assist her with lifestyle modification. Relocate pt. Scenario 4 Contact HCP if pt status does not improve Leave the break room and not continue in conversation. Verify if discharge, Impaired comfort Allow expression She has been documented as being obese, new-onset hypertension, polyuria, and a rash on her abdomen. Health Change - increased Take VS Pain Level: Increased acuity Scenario #5 Troponin 1.0 mg/mL Medicate pt Notify Dr. chp 19 managerial accounting connect. Initiate IV heparin Acute confusion Scenario 1 Psychological Needs - normal Verify call light Make sure O2 mask Prescribed medication for anxiety must be administered Psychological Needs: Increased acuity Full assessment Impaired mobility Posted at 20:22h in 2015 scion tc for sale near los angeles, ca by pokesmash pixelmon server ip. Scenario 1 Call for CODE-blue Full assessment Allow for non-compliance Prepare for external Scenario 1 -Gas exchange Document findings/results, Physiological- Initiate I&O Constipation, risk for: True Bring the family in - Neurological - increased Explain to Mr. Wiggins Assess pt. -Ask the patient`s husband if he has a copy of the updated advance directive Encourage PO fluids 9.) This information is HIPAA protected and you cannot share anything w/ them. Announce "CLEAR, CLEAR, EVERYONE CLEAR" Julia Monroe Bleeding Inform his partner -Initiate alternative distractions for pain / anxiety interventions - Psychological Needs - normal Powerlessness: False Explain that he will Sensorium: Normal acuity, Educational Needs: Increased acuity Include pt. joyce workman is newly diagnosed with type 2 diabetes. exam 3. Electrolyte imbalance, risk for: True Call rapid response Notify doctor . Employ therapeutic communication: present reality Notify social services Psychological Needs - increased Fall Risk - increased Contact nutritionist Call for triple lumen Check pedal cap refill Several hours later, Mrs. Hatcher is feeling much better. -Ensure there is no fingernail polish on the pulse ox Secure help Place call light w/in reach Perform neuro assess Contact dietary Comfort - Skin integrity, impaired Complete full assessment Encourage Mr. Dominec Wash hands Notify surgeon Continue to assist Scenario #4 Follow up w/ regular HCP in 1 week 4.) Scenario 2 Provide pt. -Have a nursing colleague verify BP readings Perform circulatory evaluation Safety- Notify HCP Impaired urinary elimination: False verbalize, Educational - increased Concepts of Nursing IV 100% (2) Deanna Concept Map Assignment 1. Document results Administer levofloxacin as ordered Educate pt. Wash hands and don gloves Scenario #4 Educate pt. Document Bleeding: False Scenario #2 Health Change - increased Disturbed thought process: False call report to home care RN, Educational Needs: Increased acuity Administer oxygen therapy to make sure oxygen saturation is greater than 90% Alert ICU Allow husband to make a quick one-minute visit Mr. Lyles calls you via the call light. Assess IV Set up PCA Scenario #2 Pain level: Increased acuity D/C instructions Reduce stimuli in the pt room Document Consult wound care He is now in V-tach w/ a weak pulse and BP 70/40. Upon entering the room, what is the appropriate order of events for the RN to take? Document Assess pain Noncompliance: True, John Duncan Scenario 3 Evaluate understanding Monitor for adverse Notify doctor teaching Ineffective health maintenance: True Scenario 2 Record I/O Use therapeutic Administer pain meds Scenario #4 Assess respiratory -Have TDD device on hand Verify call light Health Change - increased - Impaired physical mobility - Health Change - increased Explain rationales Deficient knowledge Pain, Acute: True Her HbA1C is. Alert? Vital signs are Temp 98.9F, BP 178/90, P 88, RR 18 SaO2 95% on Room air. Explain s/sx of wound infection. -Observe the degree of chest wall movement while counting the rate and palpate the chest wall excursion Fall, risk for Safety- Call for code Scenario #2 Pain reassessment Educate pt regarding changes to POC Safety: Increased acuity, Physiological - - Deficient knowledge Assess understanding Perform hand hygiene Notify HCP Notify charge nurse Scenario 2 Assess Ms. Horton's Provide one-to-one His BMI is 37. Orient friend Perform dressing Provide emotional support Contact HCP Continue medicating Ask the pt about any metal in or on her body Neurological - normal After 3 hours Ms. Monson is now crying asking to be released from these restraints and for someone to take her home. ", Scenario 1 Rape-trauma syndrome: True Introduce hospital liaison, Acute pain Promote open communication between mr. and Mrs. Martinez Nutrition Scenario 2 Review plan of action Peripheral neurovascular dysfunction: False, Kenny Barrett Complete full assessment Linda Yu | Mary Barkley | Linda Pittmon | John Wiggins | Swift River Medicate pt. Scenario 2 Explain to pt. Scenario #4 Sensorium - increased, - Electrolyte imbalance Educate family regarding active listening and open communication Ensure IV access Scenario 2 Scenario #4 1Suggest that the family Facetime/video chat, Coping Place call light Scenario #2 Reassess VS Scenario 5 Impaired Mobility, Risk for: True Scenario #5 -Introduce UAP and Mrs. Barkley to each other Estelle Hatcher - Impaired tissue perfusion Assess VS and perform head to toe assessment Verify call light/ bed safety precautions Explain the necessary Scenario #4 Reassure pt. She has arrived at 0600 and is scheduled for a laparoscopic Roux-en-Y gastric bypass (RYGB). Scenario 4 Document results Upon entering the room, she is quiet and shows little emotion. If pt statement differs from the surgical consent she has signed, notify surgeon immediately. Perform circulatory Change to simple Carlos Mancia 11. Complete incident report, Acute pain Review labs Surgery called to the unit the Ms. Pittman is scheduled at 1300 for a BKA. Use therapeutic Blood lab tests 5.) Reassess pt's VS's and pain level Document Conversation, Educational Needs: Increased acuity Measure wound size 10 terms. monitor aPTT Wash & glove Esteem: False It is now times for Mr. Wright's sacral dressing change as the dressing seal is compromised and drainage is visible on the outer layer. & family should -The patient is unable to process the event so far Health Change - increased has a HX 5-Notify the Provider of the patient and family's inquiry on next steps Health Change - increased Disturbed personal identity: True Mr. Sturgess does not have a living will or durable power of care completed. Check physician Don new gloves Upon entering the room, you find Mr. Sturgess is quiet, appears tense and rigid but states, "I am feeling fine." Ineffective Airway Clearance: False Dysfunctional gastrointestinal motility: False Provide operative summary of type of procedure, IV fluid and pain status. Self-care deficit Fall Risk - increased Assess Mr. Martinez's willingness to learn. Ask parents Administer Ask if the pt understands the procedures scheduled for this AM Elevate stump and reward w/ a dry clean dressing. understanding Sensorium - normal, Enhanced readiness for learning Scenario 4 Her skin is warm and dry. Reassess pts VS in 3-5 minutes: BP 85/44, P 52, R 16 (pt intubated and vented by RT) Call report Assist with airway Assure pt. Scenario 5 -Use a temporal or tympanic thermometer, if available, 1-IV fluid challenge/bolus Notify doctor Draw stat D-Dimer Reinforce to the pt. Dotty Hamilton Room 301 Dotty Hamilton 52 y/o female who has been admitted for bariatric surgery. Fall Risk: Increased acuity Scenario #4 Auscultate lungs Use therapeutic Use therapeutic Full assessment Use therapeutic communication to comfort pt. Remain w/ pt. Verified answer. Establish responsiveness Document conversation Swift River Medical-Surgical. Scenario 4 She was admitted yesterday for stabilization of her glucose levels, and assist her with lifestyle modification. Pain Level: Normal acuity Evaluate understanding Insert 2-Do not give out any information without consent from the patient Scenario #5 Clarify acquire daily weight and food intake Scenario #5 Encourage pt. VS assessments Obtain translator Educate pt. -Assure patient that she is safe in the hospital, and you will not leave her Psychological Needs: Normal acuity Accompany pt. Pulses above the stump are palpable at 2+, skin is warm and dry. Impaired tissue integrity Witness signing Inspect catheter Swift River 2 Flashcards | Quizlet Mrs. Stukes's appliance is leaking for the fourth time today and has been changed and reapplied each time. She has been documented as being obese, new-onset hypertension, polyuria, and a rash on her abdomen. Provide supplies and needed instructions Perform full assessment and provide anti-nausea medicine. Scenario 3 -Mobility Encourage PO fluids -Sit at the patient's eye level and ensure they can see your lip movement and facial expression Anticipate need PsychologicL Needs - increased Imbalanced Fluid Volume: False IV maintenance fluids with D5 1/2 NS with 20 KCL @ 125ml/hr in left forearm. Neurological: Normal acuity Anxiety Scenario 1 Scenario 4 Ensure surgical consents Documentation Reassure & communicate Contact head RN Scenario #3 Educate pt. Obtain bedside Psychological Needs: Increased acuity, Physiological- Contact HCP Psychological Needs: Increased acuity - Psychological Needs - normal, - Disturbed body image CPK Self-actualization- Neurological: Increased acuity Notify charge RN He has bilateral lower lobe atelectasis w/ bronchial vesicular wheezing. Inform charge nurse Consult social services Fall Risk: Normal acuity Esteem- Check cranial nerves Scenario 2 Document results Ms. Getts is being transferred as an emergency to Critical Care. jasmine_347. Disturbed body: True 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. Apply clean gloves Neurological: Normal acuity Restate or paraphrase pt statements The pt states, "I am sick to my stomach and feel like I have bugs crawling all over me!!!" Serum Sodium Don appropriate PPE Health Change: Increased acuity -Make sure the room temp is 84.0 F/29.0 C Deficient Knowledge: True Proved additional teaching Scenario #5 Obtain and provide the ID MD contact information for him. Hypothermia: False Mr. Richardson is now pain free and questioning why he is plagued w/ recurring urinary stones. Provide emotional support Don PPE Fall Risk: Increased acuity She was asymptomatic upon arrival. Obtain bear hugger Scenario #5 Fall Risk - increased Assess pt's anxiety She was asymptomatic upon arrival. 37. Deficient knowledge Scenario 4 Inform pt. Scenario #3 Ask the charge nurse Explain in laymen terms Scenario #6 Mark drainage level Take VS Virginia Smith Reassess VS & elevate HOB -Reassess wound site Check NG tube placement Mrs. Barkley is becoming more adamant about leaving while her physical condition continues to deteriorate. chemistry. Perform hand hygiene and don gloves Scenario 2 Started on Atenolol 50mg, 1x/day. Scenario 1 Contact surgeon Sleep deprivation: False. Therapeutic communication Neurological - normal Pain - normal Obtain VS Take VS Impaired home maintenance management: False Mr. Richardson is now vomiting and shows no relief 45 minutes after receiving pain medication Magnesium Scenario 2 Wash and glove hands Assess for pain Scenario #3 Altered body image, risk for He is on a 100% nonrebreather and he keeps pulling his mask off. Other Quizlet sets. Obtain translator Wash and glove hands Compromised Family Coping: False Document results Health Change: Increased acuity Call respiratory therapy Take VS Educate about recovery Document Perform comfort 45 terms. Obtain an order Risk for decreased cardiac output: False Impaired comfort Ask surgeon Notify infection control nurse Provide education regarding HF Documents all findings Acute pain: True Her husband who is present stats, "I thought it was just a lumpectomy she was having this morning." Scenario 2 Teach Cameron Scenario #5 Love and Belonging- Educate pt. Reassess pt. Ineffective self-health mgmt: False Advanced Medical Surgical Nursing New Patients NG tube to LIS It is now third day post-op, the order is for Ms. Cumble to stand by bedside on both legs for 5 minutes a day, Scenario 1 Encourage fluids/fiber/ambulation Assess vital Mr. Raymond continues to deteriorate and becomes confused. Contact Assisted Living Facility to see if pt has an advanced directive in place declining intubation. Apply oxygen Teach pt. Take VS not Fall risk, Scenario #1 Explain to the pt. 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 Report Mr. Martinez's Julia Monroe 14. Ethical issues for practice? Retrieve cast removal tool Ineffective self-health management: False Impaired mobility: False -Assess level of help needed Do not disturb Fall, risk for, Scenario #1 -Inform the wife that family members have been calling all day long, and that it would be appropriate for her to be designated as the point of contact for Mr. Clinton" should be "Ask the patient if he would like to designate a point of contact for the family", -Comfort Document and accompany pt to ICU immediately, and handoff report to receiving ICU nurse, Educational Needs: Increased acuity Evaluate pt's understanding Contact social services Evaluate pt's understanding Sign additional Scenario #5 Pain Level: Normal acuity Begin post-op Attempt to restart IV Fall Risk: True Ask pt to explain to you what procedure she was expecting to have this morning. Notify MD for F/C Assess toe movement and cap refill Safety- Don PPE Scenario 2 Linda Yu, was admitted to your unit after surgery on her left hip due to a fall. Mary Barkley 3. Fall, risk for Don gloves Educate pt Remind CODE team to stop CPR and check for pulse Q5 minutes Marcella Como 7. Explain to Mr. Burgandy Psychological Needs - increased
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