Notify respiratory therapy Check nose and ears Attempt to restart IV Linda Pittmon Room 304 Glucose level? Educate about recovery Scenario 4 Repeat neuro Psychological Needs - normal - Impaired comfort Neurological: Normal acuity -Remain with the patient Scenario #2 if she She is requesting the names and home phone number for the wound care nurse who saw Mrs. Stukes while she was an inpatient. - Skin integrity, impaired She appears short of breath when talking. 44 terms. Check surgical consent Verify call light/ bed safety precautions Scenario 2 Clinical 2. Obtain 16 gauge angiocath Document results and findings Pain - increased Impaired comfort Risk for impaired comfort Swift River- Pediatrics. Notify lead RN and Dr. Visual assessment Discuss with HCP Employ therapeutic communication: present reality Scenario #2 Reassess VS & obtain UA Assist RRT - Electrolyte imbalance, risk for Notify Dr. Reinforce to the pt. Escort pt to ER for a physical and psychological evaluation Ineffective coping 2-Insert the indwelling urinary catheter understanding, Acute pain Impaired mobility: True She puts her call light and asks to see a RN. arrival Document results and findings Scenario #2 Document results Contact dietary consult Document Administer nebulizer Sleep deprivation: False. Scenario #2 diagnosis of type II diabetes. Encourage positioning He is on a 100% nonrebreather and he keeps pulling his mask off. You, the RN, are concerned because the family asked for everything to be done and the pt never signed a DNR order. Assess VS and perform a neurological focused assessment Fall Risk: Increased acuity Health Change - increased Impaired skin integrity, risk for: True Ineffective health maintenance: True 1 Administer a mini-mental state exam Scenario 1 Consult social services Wash hands Course Hero is not sponsored or endorsed by any college or university. Document results Administer medication Remind pt. CPK: 360 mcg/mL Neurological - normal, Impaired mobility, risk for Powerlessness: True Full assessment including both lying/standing Impaired Comfort: True Retake VS (BP 110/70, P 94) Tell husband & pt. Reposition HOB to semi-fowler's Observe & mark Fall Risk - normal 4-Provide necessary equipment Scenario #5 Complete full assessment Impaired home maintenance management: False Wash and glove Alert ICU Learn vocabulary, terms, and more with flashcards, games, and other study tools. ineffective breathing pattern: False Therapeutic communication Reassess its VS Mark Robinson 17. Delay insertion of IV Scenario #3 IV fluids of D5 1/2 NS are infusing at 100 mL/hour to his right forearm. Don PPE Decisional conflict: False -Draw Labs early Assess dressing supply Anxiety: True Mr. Raymond weighs 260 lbs. 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. Don gloves Impaired gas exchange, risk for In reassessing Ms. Monson, her VS are BP 106/82, T 98.2, P 106, R 18, SaO2 88, Scenario 1 Psychological Needs - normal Evaluate pt. Auscultate lungs Upon entering the room, you wash/glove hands. Paroxetine (Paxil) 30mg PO everyday. ambulate Tell the pt. Acute confusion: False Pain - increased - Fear Scenario 4 Notify respiratory therapist to begin tx Alert Mr. Wright's case manager Mr. Richardson is now pain free and questioning why he is plagued w/ recurring urinary stones. Document education, Educational - increased Mr. Sturgess is uncomfortable w/ experiencing urinary frequency that keeps him from resting Determine from medical Scenario #2 Psychological Needs - normal, Bleeding, risk for Fall Risk: Increased acuity - Health Change - increased A group of university students conduct a survey regarding menstrual pain for their biology subject. Remove the dinner tray Sensorium - normal, Scenario #1 Document results Contact charge nurse -Coping Introduce hospital liaison, Acute pain Inspect cast site Safety- Neurological: Normal acuity Scenario #1 -Mobility Evaluate understanding Gas exchange, risk for Assess Mr. Jones VS are BP 80/40, P 46, R 16, (pt now intubated and ventilated by Respiratory Therapy), Scenario 1 Administer ABX & start morphine elisabeth_hamilton. Notify lead RN/Dr Full assessment Review plan of action Several hours later, Mr. Duncan is now complaining of nausea. Position the pt properly Scenario 3 Evaluate/modify plan of care Fall Risk - increased 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. - Sensorium - normal, - Acute pain Administer oxygen Complete full assessment Request sitter/family member to bedside Verify with blood bank Preston Wright, 73-year-old male patient of Dr. Greene, status post CVA 4 weeks ago. -Direct patient back to her room Assess Mr. Wright's willingness to learn. Who were you talking to? Explain to the pt. Administer Valium Scenario #5 Infection, risk for, Scenario #1 Educate pt-STD's and pregnancy - Neurological - increased consult social service Mr. Raymond, COVID-19 positive, in severe respiratory distress, RRT called Comfort the pt Document Scenario #2 She has been documented as being obese, new onset hypertension, polyuria, and a rash on her abdomen. 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; . Initiate secondary At 2200, you enter the room and the pt states pain is now 10/10 after not having any pain for 3 hrs. Health Change: Increased acuity Measure nose to ear Obtain blood for lab testing and blood culture #1 Check time Obtain additional support Arthur Thomason 16. Explain to the pt. -Wait until anesthesia evaluates the patient and have them assist in restarting the IV. 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 Document Disturbed energy field: True Explain to her family Contact HCP 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. Anxiety: True Address pt's skin tear Reassess pt. Health Change - increased Evaluate understanding Notify HCP Stop the pt. Attempt deescalation Pt. Assess Ms. Horton's Apply restraint 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. Evaluation pt after consult Study with Quizlet and memorize flashcards containing terms like Tim Jones, Tim Jones, Tim Jones Scenario 1 You begin your shift assessment w/ Mr. Jones Scenario 2 Mr. Jones is scheduled for a full body CT scan. Assess VS and perform head to toe assessment Request the uncle come Provide SBAR Reapply restraints Decisional conflict: True I am concerned about keto-acidosis and the complications of hyperglycemia. -Gas exchange - Infection, risk for, Scenario #1 Explain to the pt. Ineffective self-health mgmt: True Obtain an order to insert a Foley catheter Your response to all of them would be: Scenario 1 Explain to Mr. Wiggins Initiate incident report, Acute pain Assist Mr. Jones -Remind students of HIPAA policy, and report observations to the Nursing professor Spiritual distress: False Scenario 2 Call RRT, rapidly prioritize the following Explain to pt. Give 1mg atropine The nurse has another high acuity admission that has just arrived from the ER. Document results, Physiological- impaired comfort Scenario 3 Scenario #5 - Impaired skin integrity on telemetry Put side rails up Fall Risk: Increased acuity Scenario #3 Draw stat D-Dimer Call HCP Schedule Cardiac rehab & VS, Educational - increased Administer pain meds Prepare to initiate cardioversion. Health Change - increased Sensorium: Normal acuity, Physiological - Monitor and evaluate Mr. Richardson is requesting assistance to ambulated to bathroom Start O2 Ineffective breathing pattern: True Rank as most concerning for labs Scenario #4 Scenario 3 Scenario #2 Safety: Increased acuity Ensure informed consent Nausea: False Create sterile field w/ foley kit on the bedside table and don sterile gloves. Assess respiratory Scenario 2 Nutrition Safety: Increased acuity, Physiological - Make sure accurate wt. Imbalance nutrition: True You now arrive in the recovery unit one hour post-surgery and you are told that the surgery went well. Provide introductory Pain, Acute: False She has been documented as being obese, new onset hypertension, polyuria, and a rash on her abdomen. Elevate stump, - Educational - increased Her HbA1C is. Full assessment -Rate patient's pain on a scale of 1-10To determine level of pain for intervention Scenario 5 Reassess pts VS in 3-5 minutes: BP 85/44, P 52, R 16 (pt intubated and vented by RT) VOCN300 Swift River Medical-Surgical American Career College 1. Initiate anti-psychotic meds Explain procedure Ask if the pt understands the procedures scheduled for this AM Self-care deficit 500 mL NS bonus Offer resource assistance to caller Scenario #2 Scenario 1 Escort pt. Sacrum pressure injury demonstrates underlying bone exposure wound measures 4cm x 6cm x 3cm depth w/ tunneling noted on the rt side. Ask nursing manager, Acute pain -Make sure the room temp is 84.0 F/29.0 C Esteem- Scenario #4 Health Change - increased Administer digoxin Don 2nd set of clean gloves to provide stump care. Assess extremity Educate about recovery from appendectomy and care to wound. Scenario 3 Wash hands Impaired comfort Present health assessment -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 Educational Needs: Increased acuity Scenario #2 Contact funeral home Psychological Needs: Normal acuity Explain to pt. Document results/findings Complete skin assessment Notify charge nurse that d/c will probably not occur today. Obtain VS Evaluate understanding Document Body image disturbance: False The surgeon added oxycodone 5mg q 4-6 hours prn pain. Nausea, risk for Contact head RN or supervisor in the OR to evaluate new situation. 4-Place 100% non-rebreather on the patient In the afternoon, Ms. Como is stating that she does not want to see her husband or any visitors.
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