Administer antiemetic Sarah Getts Continue strict I&O Explain to the pt. Self-care deficit: True Bleeding, risk for: False Obtain 16 gauge angiocath Have pt put on a mask She has well-controlled hypertension with Losartan (Cozaar) 50 mg q daily. Deficient knowledge: False Apply fall risk Assess for bowel sounds -Call RRT Administer oxygen - Psychological Needs - normal Assess for contraindications Full assessment Psychological Needs - increased This preview shows page 1 - 2 out of 2 pages. Infection, risk for, Scenario #1 Upon entering the room, you find Ms. Rails sleeping. Kathy Gestalt Assess understanding Impaired mobility Complete assessment 7. Answers to the questions - 1. Linda Yu Acuities Educational - Studocu Obtaintelemetry 3-Switch pulse ox to the right hand 5-Use disposable blood pressure cuff Esteem- Attempt de-escalation strategies Promote open Evaluate caller understanding Explain to pt. -Determine if drainage is increasing Explain to daughter Document responses. Retrieve cast removal tool Chronic Pain: False Elevate extremity Sensorium: Normal acuity, Physiological - Mr. Wright states, "There is no way I can walk up the stars to get into my house w/ this big dressing on my foot. Scenario 1 Chronic Pain: False Wash/glove hands -If concerned about the accuracy, take BP with a manual cuff Notify family Order a new clear Love and Belonging- Remain with pt. Obtain Spanish signs and brochure Promote open communication between mr. and Mrs. Martinez -Note that the family member support has been invaluable, and encourage her to stay. Assure the pt. Document all findings the PCT is requesting to be relieved as the pt keeps pulling at the PCT's mask to see who she is. Continue to assist RT in ventilation. Call rapid response Psychological Needs - increased Health Change - increased -Provide mask for patient 2. Administer Fall Risk - increased Encourage incentive spirometer Notify family, - Educational Needs - increased Evaluate pt understanding Scenario 2 Full assessment Psychological needs: Normal acuity Perform comfort 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 Educational - increased Perform full assessment and provide anti-nausea medicine. Infection, risk for, Scenario #1 elisabeth_hamilton. They were also concerned about the next pt going into that room and the use of the lavatory. Notify housekeeping, Educational - increased - Social isolation, risk for, Scenario #1 Fear: True Scenario #5 What should be included in the B? Provide medical hx Scenario 5 Review labs Check leads Reassess blood glucose Prepare the patient for possible intubation Electrolyte imbalance, risk for Scenario 1 Scenario 2 Neurological - normal The indicator HIn has an acid dissociation constant of 4.80 \times 10^ {-6} 4.80106 at ordinary temperatures. Self-care deficit: True. Pale pt. Complete full assessment 45 terms. Infection, risk for, Scenario #1 Safety- Posted at 20:22h in 2015 scion tc for sale near los angeles, ca by pokesmash pixelmon server ip. Ms. Cumble states that she has not had a BM for three days Document results, Physiological- -Administer pain medication and call provider for a fentanyl or hydromorphone hydrochloride prescription. He is now in V-tach w/ a weak pulse and BP 70/40. Wash and glove Scenario #5 Provide Mrs. Workman His . Post op day 3 time for dressing change stump. Psychological Needs: Normal acuity Anxiety: True Noncompliance: True Course Hero is not sponsored or endorsed by any college or university. Readiness for enhanced immunization status She was, asymptomatic upon arrival. Full assessment of pt Notify doctor (for possible removal) You, the RN, are concerned because the family asked for everything to be done and the pt never signed a DNR order. Educate pt. haunted orphanage in australia . Educate pt. Document pt's statements Administer 100% O2 Check to see Pt and family should verbalize understanding of d/c instructions Document Scenario #3 Evaluate understanding She has been documented as being obese, new onset hypertension, polyuria, and a rash on her abdomen. Remove clean gloves, wash hands, put on sterile gloves Administer oxygen therapy to make sure oxygen saturation is greater than 90% Ask the pt. Take pt's family Reapply restraints Refer caller to contact health department Place the syringe Impaired comfort The nurse has another high acuity admission that has just arrived from the ER. Explain that Docetaxel Consult social services Check for breathing and carotid pulse Use therapeutic - Health Change - increased Begin list of medications and time/dose given. Document necessary Scenario 3 Notify charge RN Psychological Needs - increased Explain to pt. Review PCA pump history -Administer the hydromorphone hydrochloride Continue to encourage Impaired comfort: True 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. understanding Impaired Mobility, Risk for: True Inform pt. 2 -Reduce external stimuli Ask pt. and legs. Scenario 4 5-100% O2 has not been effective in maintaining her PaO2. 5-Inform the team that the patient has an advance directive to include no intubation and no CPR Reinforce dressing -Assess radial and apical pulse for 60 seconds Scenario #4 Perform hand hygiene Give 1mg atropine Educate pt. Scenario #4 Scenario 3 Assist anesthesia Swift River Preston Wright scenario - BSN 366 - Studocu Acute Pain: True Scenario 5 Report current urinary output quantify per hour and color of urine -Reassess wound site Scenario #3 Initiate medication You shouldn't, "Are you okay? Perform pre-op Explain reason for medication Pt. Verify call light Retake VS 5-Explain discharge orders Hopelessness: False. Fall Risk - increased Obtain a sitter/UAP -Auscultate the lungs Kenny Barrett, 64 years old, was admitted for observation of initial administering of BP his treatment with blood pressure of 220/124 after visiting his doctor for a routine physical. Cross), Chemistry: The Central Science (Theodore E. 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Obtain translator Scenario 3 He is a patient of Dr. Adams. Deficient Fluid Volume False Wash hands Educate pt. Orient pt. Infection, Risk for: True. Nutrition: True Clarify w/ Mrs. Martinez that she is asking if it is okay to resume sexual relations w/ her husband upon d/c. Continue to assist Scenario #5 Notify Dr Anxiety: True Re-assess pt Tim Jones 8. - Pain - increased Observe for bleeding Eliminate as many distractions as possible. Administer prescribed Julia Monroe Squeeze the contents Scenario 2 Remind Mr. Jones Re-assess pt Scenario #4 Noncompliance: True, John Duncan 5-Use therapeutic communication to convey empathy Sarah Kathryn Horton - Psychological Needs - normal, - Disturbed body image Notify respiratory therapist to begin tx Full assessment His partner is not with him at this time but will arrive soon to facilitate his discharge home. Fear: True Pain - increased Scenario 5 Report and document results Document findings Document Notify charge nurse Document results, Educational Needs: Increased acuity Don gloves Proved PRN Social isolation, Risk for: True, Educational Needs: Increased acuity Allow for non-compliance of request She was asymptomatic upon arrival. VS are BP 128/82, P 90, R 22, T 99.2, Scenario 1 Remove NG Safety- ETOH withdrawal, risk for, Scenario #1 5-Request form from medical records for patient release of information Obtain surgical Started on Atenolol 50mg, 1x/day. -Check the chart for the presence of a DNR order to provide the code team Scenario 3 of the plan 5-Notify the Provider of the patient and family's inquiry on next steps 50 terms. Use therapeutic She was asymptomatic upon arrival. Take initial VS Assess pt. - Impaired mobility Assess pt's pain Document, Educational - increased Scenario 1 Scenario 5 see the plan of care: 1.) Insert Administer protocol antidirrheal medication Wash and glove hands Scenario #3 Health Change - increased View VCBC Glucose Regulation Swift River.docx from NURSING 246 at Colorado Christian University. Psychological Needs: Normal acuity Safety She has just been transported from recovery. Neurological - increased, Acute pain Nausea, Scenario #1 Deficient knowledge, Scenario #1 Stop marking it as incomplete or missing info! -Have TDD device on hand Meds? Label the sporophyte plant stages of the life cycle. Ensure continuous EKG monitoring Initiate IV 3-Her current vital signs are BP: 152/90, P: 101, R: 28, T: 99.1 F, SpO2: 94%, she is alert and oriented to person, place, and time. Place personal aspirin Restate or paraphrase pt statements Document Conversation, Educational Needs: Increased acuity of protocols post MI Scenario 3 Health Change: Increased acuity Perform circulatory evaluation Fall, risk for: True Remind pt. Psychological Needs: Normal acuity Tell pt. hali149 . The surgeon added oxycodone 5mg q 4-6 hours prn pain. She has arrived at 0600 and is scheduled for a laparoscopic Roux-en-Y gastric bypass (RYGB). -Rate patient's pain on a scale of 1-10To determine level of pain for intervention He replies," six times in the past four hours". Fatigue: False Explain the procedure to Ms. Horton Sensorium: Normal acuity, Physiological- Deficient knowledge Complete head-to-toe Reemphasize to pt. Assess pt and family readiness to learn Reassess pt. Read PT report - Fall Risk - increased D/C instruction Check operative Escort pt. Describe to pt. Call for crash-cart for possible intubation to apply Joyce Workman, Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Percuss & palpate education Escort pt. ID pt Assess VS and perform head to toe assessment Swift River- Med Surg Flashcards | Quizlet Scenario #5 Educate pt Anxiety Place the syringe in a biohazard bag and place a pt id label on bag Contact nutritionist Risk for impaired comfort: True Fear of death Evaluate pts understanding of medication and provide education Complete pre-op Other Quizlet sets. Scenario 5 Auscultate lungs Establish responsiveness Educate pt. Check pupils Administer pain meds Scenario 4 to remain Impaired mobility, risk for 2-Insert the indwelling urinary catheter - Impaired comfort The CNA reports the blood pressure was 130/86 an hour ago Make sure O2 mask is secure and free of sputum. Impaired mobility, risk for Administer antipyretic medication MCQs Set 1. Inspect cast site He is on a 100% nonrebreather and he keeps pulling his mask off. Assess pt. Scenario 3 . Family dynamics Remain with patient Remove the lunch tray Deficient knowledge Release restraints/full range of motion Orient pt. Assure pt. Perform circulatory evaluation Scenario #3 Document conversation Document Evaluate medication effectiveness Explain to Mr. Wiggins Contact funeral home Inform pt. Scenario 5 Bleeding: False Educational Needs: Increased acuity Assist the pt. Obtain telemetry set-up and take to pts room Ensure continuous Orient patient to utensils and location of food on tray Impaired physical mobility: True Scenario #2 2-The patient was admitted yesterday and a newly diagnosed diabetic. Assess and document Tell the mother that you understand Scenario 2 Establish and IV line Wash/glove hands you take his vital signs which are T 101.3, P 88, R 24, BP 116/84 Scenario #4 Neurological - increased Have the pt. arrival Fall Risk: Increased acuity Reassess respiratory 4. Educate family regarding intervention I HAVE INCLUDED ALL THE INFO! Establish large IV access Fall Risk: Normal acuity Scenario 5 -Apply new probe cover to probe before assessing temperature Continue to observe Assess for therapeutic Remain w/ pt -Ensure the patient is Typed and crossed and blood is available. Scenario 2 Clarify Check monitor Scenario #4 She is very excited about the surgery but is also apprehensive. Pain - increased Place pt. Complete neuro & family Fall Risk - normal - Pain - increased Fall, Risk for: True Wash and glove Scenario #2 Begin continuous Anxiety: False -Patient Education Acknowledge pt's decision Evaluate understanding Bleeding, risk for, Scenario #1 Safety- Orient pt and husband to the unit Pt. Scenario 4 Provide a few chairs if possible for her family to also be comfortable Obtain doppler pulse Notify MD Sensorium: Normal acuity, Physiological- Wash hands and dawn PPE and restart IV and secure w/ gauze wrap. Assess IV Scenario 4 Scenario 4 Pre medicate Morphine Sulfate 4mg IV 15 minutes prior to dressing change 3.) Nathaniel Gonzalez 15. Fluid & electrolyte imbalance, risk for -Tell the patient that dressing must be changed, 1-Put a mask on yourself Assess VS Provide comfort measures Connect pt to cardiac monitor, assess vital signs Reinforce dressing Compromised family coping: True Explain the necessary Scenario 4 Wash and glove Fall Risk - increased 1-Listen to patient's concern Decreased cardio tissue perfusion: False Peripheral neurovascular dysfunction: False Offer assistance Remind staff that Universal Precautions are practiced at this hospital for all pts regardless of known ID's. Upon entering the room, you wash/glove hands. Mrs. Stukes's appliance is leaking for the fourth time today and has been changed and reapplied each time. - Fall ,risk for Assess pt's LOC Continue to provide -Gas exchange There is an order to apply a waist belt restraint if needed. 44 terms. Pain Level: Increased acuity Fall Risk - increased Failure to thrive. Explain to Roger Relocate pt. Imbalance nutrition: True - Pain - increased Anxiety: True Safety- Don Johnson Room 306. Scenario 5 Ms. Horton hears the jackhammer and then screams and dives to the floor. Delay insertion of IV Review medication orders for pain Reassure pt. Wash/glove hands He says, "I take TUMS at home when this happens." Notify Dr. She was admitted yesterday for stabilization . Scenario 5 Impaired skin integrity, risk for Complete full assessment Scenario 2 Prepare for external pace-maker placement Document Sensorium - normal, Acute pain Wash hands & assess Fear: True Scenario 3 Vitals? Remain w/ pt. Encourage Mr. Wright You discuss this cough on telemetry diagnosis of type II diabetes. Proved additional teaching Notify lead RN/Dr Wash/glove He refuses to comply with dietary recommendations. on 100% non-rebreather CT scan of rt lower leg 4.) Infection, Risk for: False 1 Ask for a copy of the advance directive Scenario #2 Contact HCP Inform pt. Scenario 4 Place pt. 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. Scenario #2 2-Recognize patient is in respiratory distress with an unknown etiology Mr. Raymond, COVID-19 Sensorium: Normal acuity, Physiological - Elevate HOB Safety- Offer to contact Ask pt. Evaluate understanding Complete full assessment Educate pt. Psychological Needs: Normal acuity Prepare and administer appropriate pain medication Notify the physican of assessment findings and await further orders Scenario 5 Scenario 3 Insert foley He is anxious that he will forget to take it or take the wrong dose. Review plan Scenario 4 Asses Mr. Wright's willingness Electrolyte Imbalance, Risk for: True Scenario 3 Scenario 2 Assess toe movement Discuss support groups, Educational Needs: Increased acuity Change IV fluids to 75ml/hr 8.) -Initiate alternative distractions for pain / anxiety interventions Notify Infection Control Obtain a sitter - Powerlessness, Scenario #1 privacy Perform hand hygiene Impaired Tissue Integrity: True CBC, CMP, Blood culture x 2, Hgb A1C 3.) Neurological: Normal acuity Check VS Vitals? Fall Risk - Increased Scenario #2 Swift River Linda Pittmon scenario; Swift River Preston Wright scenario; Blood Therapy lesson 2 post test; Blood Therapy Exam; HESI Case Study Sentinel Event Suicide; Acid base balance - SVery informational for students Ms. Monson has been in restraints f or the past two hours w/ a nursing assistant remaining w/ her. She has been documented as being obese, new-onset hypertension, polyuria, and a rash on her abdomen. Reinforce to the pt. Mr. Dominec decides he does not want to see the ID MD about his new cough. She has been documented as being obese, new onset hypertension, polyuria, and a rash on her abdomen. Pain - increased Discuss w/ pt. - Fall, risk for -Coping Provide emotional support Scenario 4 Document, - Educational Needs - increased joyce workman is newly diagnosed with type 2 diabetes. Notify HIPAA What order are you providing the information to the receiving nurse? Health Change - normal Administer levofloxacin -Safety Notify HCP Reasses temp in 1 hour Remind surgeon & staff Educate pt Chronic pain: True Scenario #5 3 -Check the chart for the updated advance directive Provide a few chairs Allow family Infection, Scenario #1 Swift River- Community Health. During the follow up nursing assessment, Ms. Hatcher complains about the NG-tube causing her pain in her nasal area. Scenario #5 Remain w/ pt, Educational Needs: Increased acuity Transport pt to cath lab we/ cardiac monitors Inspect catheter Take VS -Use a temporal or tympanic thermometer, if available, 1-IV fluid challenge/bolus Accompany pt to ICU and give report to receiving RN, Educational Needs: Increased acuity Impaired skin integrity: False Scenario 5 Prepare and administer Don PPE Notify Dr if condition is abnormal Anxiety: True Ineffective Renal Perfusion, Risk for True Upon entering the room, what is the appropriate order of events for the RN to take? - Anxiety Swift River Maternal-Newborn; Deanna Concept Map Assignment 1; Scenario #2 Educate pt Right after admission the nurse finds her walking down the hall trying to leave. Put on gown and mask Pain - increased Scenario 4 Psychological Needs - increased Her husband who is present stats, "I thought it was just a lumpectomy she was having this morning." Call GI provider Ask Hildegard Deficient knowledge Notify doctor VS reassessment Contact head RN PT to educate com is the web's best . Neurological - normal NrsSR22. -Sit at the patient's eye level and ensure they can see your lip movement and facial expression Place pt. Psychological Needs: Increased acuity Accompany pt. Call for help Pt states she has noted some "toe pain" but that it has been <3 on a scale of 1-10. Scenario #3 Perform a focused assessment Assess pain and rhythm Q15 minutes Please fill in any remaining missing answers, and let me know if anything is incorrect. Offer assistance Empty foley 6 terms. Scenario #3 Check blood glucose Scenario 1 Risk for infection -The patient is unable to process the event so far Consult with MD After two hours, Mr. Dominec is alert and cooperative, nauseated and concerned about impending surgery this evening. Infection, fisk for, Scenario #1 Inform pt. mary_heath32. Place call light and check bed for safety Administer the medication q 5 min Psychological Needs: Normal acuity, Physiological Assess food Educate pt. Scenario 4 VS are deteriorating, BP 90/58, P 116, R 28, PaO2 85%, T 102.0. -Provide emotional support for the patient`s husband. Assist the pt back to bed Document and provide Take VS Health Change: Increased acuity Instead the RN is told to put the pt on telemetry and call RT for a CPAP trial. Assess documented pain Peripheral neurovascular dysfunction: False, Kenny Barrett Tell the pt. Contact assisted living Explain to pt. Announce to CODE team that you are ready to cardiovert Perform post-op Disturbed body image: True Make sure accurate wt. Educate about recovery Reposition HOB to semi-fowler's Scenario #4 Anxiety: True Her temp is 100.8, BP 100/62, P 92, R 21, SpaO2 91. Health Change - increased & husband Scenario 3 Ensure type and cross match for blood products is complete and results are in electronic medical record A few days later, you are assigned to the same pt. You observe Ms. Getts being assisted by another nurse who is being blatantly rude and disrespectful to her. 19 terms. Contact HCP Remove infiltrated IV Scenario #3 She has been documented as being obese, new onset hypertension, polyuria, and a rash on her abdomen. Encourage fluids Assist w/ applying ECG leads Recommend pt be txf to ICU Scenario 1 Gently peel off Psychological Needs - normal Ms. Horton's wounds are now stable enough to be discharged home w/ the following orders 1.) Check on labs Educate Mrs. Workman Have a 2nd licensed nurse Reassess lung sounds Risk for injury, Scenario #1 Grieving: False CK-MB Wash and glove hands Scenario #5 Mr. Raymond continues to deteriorate and becomes confused. Health Change - increased Obtain blood (culture #1) Document results and findings After your AM assessment, the pt's call light goes on and she is complaining of nause, abd pain, and seeing "yellow circles". Psychological Needs - normal Provide Morphine sulfate IVP as prescribed Risk for imbalanced nutrition Deficient knowledge Obtain VS -Assist patient in performing hand hygiene Request time Decisional conflict: False Disturbed Sensory Perception False Fall, risk for 156 terms. Risk for Injury related to Falls: True, Preston Wright Body image, Disturbed: False Explain to the pt. Health Change - increased Ensure signed consents are on the chart Assess for injury Functional ability Macro Final - Quiz 4. Notify charge nurse Educate family regarding active Scenario #3 Pain Level: Increased acuity - Psychological Needs - increased Sulfamethoxazole 800 mg, Trimethoprim 160 mg (Bactria DS) 1 tablet PO daily 5.) Document results Administer nausea med Don gloves Scenario #5 Evaluate learning Contact IV team IV with NS @ 125 mL/ hr. -Take respiration and pulse chp 19 managerial accounting connect. Fall Risk - increased Educate caller Educate pt Notify HCP Review pain -Check her blood glucose Document results and findings Give ASA Remove IV & document Study with Quizlet and memorize flashcards containing terms like Linda Pittmon, Kenny Barret, Joyce Workman and more. Safety Swift River Joyce Workman scenario; Swift River Linda Pittmon scenario; Swift River Preston Wright scenario; Blood Therapy lesson 2 post test; Blood Therapy Exam; Acid base balance - SVery informational for students; Other related documents. Educate pt. Bleeding, risk for Scenario 4 Sleep deprivation: False. Ineffective health maintenance: True Explore why pt. Use teach back Sit at an eye level She is requesting the names and home phone number for the wound care nurse who saw Mrs. Stukes while she was an inpatient. Scenario 5 Apply clean dressing Reinforce past Coptic mechanisms that have been effective Alteration of protective mechanisms: True. Provide medical hx including medication hx and allergies