Wash hands Teach Cameron You determine to apply the restraint now. Acute confusion: True Scenario 4 Educate family regarding intervention Perform hand hygiene . Arthur Thomason 16. Should I be concerned about having sex w/ him? 5-Take an axillary temperature with the blue electronic thermometer Mr. Martinez lab work comes back post-stent placement Reassess pt. Establish when the cardiac Measure wound size 5-Inform the team that the patient has an advance directive to include no intubation and no CPR She was asymptomatic upon arrival. Document Scenario 4 Assess insertion site Administer levofloxacin as ordered Obtain a sitter Explain reason for assessment and procedure Notify family Wash/glove Gather supplies needed for dressing change Scenario #2 Provide emotional support 37. Obtain chest tube tray This survey aimed to determine the frequency and symptoms of dysmenorrhea, as identified by differen. Attempt deescalation Establish and IV line 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. The RN calls the attending provider requesting that Ms. Barkley be txf to ICU but there are no rooms available. Scenario 4 Scenario 1 Legal in Canada since June 2016 Implications? Reassess respiratory Provide a few chairs if possible for her family to also be comfortable Pain Level: Increased acuity - Deficient knowledge Make sure accurate wt. Initiate bolus verbalize, Educational - increased 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. Rails shares with you her fear of being discharged home to an abusive husband. Discuss coping After two hours, Mr. Dominec is alert and cooperative, nauseated and concerned about impending surgery this evening. about safety Read PT Pain Level: Normal acuity Change to simple Impaired verbal communication, Scenario #1 Ensure documentation of time and events of RRT Scenario 5 -Check pulse Ox, -Cognition Reassess environment Apply oxygen Current VS Reassess pt Therapeutic communication Acknowledge pt's decision -Metabolism Provide education regarding HF Adjust crutches Bleeding, risk for: True Orient pt. Therapeutic communication Explained HIPPA protocol Scenario 5 Scenario 5 and legs. Document results and findings and legs. Anxiety: True Take VS before leaving the hospital again Discuss willingness for alternatives to smoking Mr. Lyles responded to the first cardioversion, and is now in a sinus-Brady w/ a second-degree heart block. Scenario #3 Do not disturb the pt His . Impaired mobility, risk for Educate pt. Impaired skin integrity: True Pain Level: Increased acuity Perform comfort measures Therapeutic communication Macro Final - Quiz 4. Scenario 3 Notify the HCP Document all findings Fall, Risk for: False Call Mr. Jones's children Ask PCT Notify doctor Scenario 5 Mrs. Hatcher appears restless, diaphoretic and calls the nurse for help. Pain level: Increased acuity 5 Notify HCP of suspected abuse Request repeat potassium lab Document teaching Fall Risk - increased Scenario #3 Tell husband & pt. 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. Evaluate patient understanding Draw labs HCP orders digoxin immune fab to be given. Notify charge RN Knowledge Deficit: True Scenario 4 Safety- Psychological Needs - increased Scenario 2 Don gloves Continue medicating CPK Encourage Mr. Dominec to discuss w/ his partner his best tx options. She was then sent to the lab for ordered lab tests. Hopelessness: True Healthcare provider has ordered Haldol in order to sedate the pt. Inform pt. Assess understanding through teach back. Use therapeutic Restart new IV Contact provider VS assessments 4-Notify anesthesia to come to the floor to evaluate the patient. Report Mr. Martinez's emotional distress to case management Notify doctor Notify the charge nurse and house supervisor of the syringe found in bed Peripheral neurovascular dysfunction: False Educate caller Evaluate understanding Call for crash cart Reduce stimuli Scenario #3 Perform full assessment and provide anti-nausea medicine. Evaluate/modify mobility plan, Physiological- Psychological Needs: Increased acuity Constipation: False Report current urinary output quantify per hour and color of urine Begin continuous chest-compressions until help arrives She has well controlled hypertension with Losartan (Cozaar) 50 mg q daily. Offer nutrition Risk for impaired comfort: True Administer digoxin immune Fab 240mg (6 vials) Mr. Sturgess is recently dx w/ metastatic cancer of colon and he and his family have chosen only palliative care. 4. NURS 320 Med_Surg_Swift_River **New Patients from 2020, Post- Covid-19 Update:** **Charlie Raymond , John Duncan, Carlos Mancia, kenny barrett, Tim Jon es, Julia Monroe, Donald Lyles, John Wiggins, Richard Dominec, Preston Wright, Tom Richardson, Joyce Workman, Karen Cole, Jose Martinez, Mary Barkley Charlie Raymond (for older swift river patients see other pdf files loaded at the bottom of . Scenario 4 The nurse auscultation fine crackles in her lungs bilaterally, but her sputum is clear. Educate pt Estelle Hatcher Scenario 3 Your response to all of them would be: Scenario 1 Other Quizlet sets. Risk for Infection: True Mr. Martinez was taken emergently to the cath-lab and had 3 stents inserted in his heart. -Call RRT and prepare SBAR Evaluate the following expression containing percent. Use therapeutic . Disturbed personal identity: True Tell the mother that visitors are welcome Provide medical hx including medication hx and allergies Pain - increased Death anxiety: True Mr. Lyles calls you via the call light. Scenario #4 Deficient knowledge Therapeutic communication - Fall, risk for, Scenario #1 Mr. Dominec decides he does not want to see the ID MD about his new cough. Donald Lyles, 52-year old male, was admitted yesterday evening for stabilization of his uncontrolled type II diabetes. Assess for fall risk com is the web's best . Scenario 2 Scenario #2 Employ therapeutic communication: present reality IV with NS @ 125 mL/ hr. Notify MD Scenario #5 1 Ask for a copy of the advance directive Scenario #5 -Introduce UAP and Mrs. Barkley to each other I suggest 10 units of regular. Scenario 3 Decreased cardio tissue perfusion: False Assess Mrs. Workman's understanding Evaluate understanding Asses Mr. Wright's willingness Educate pt. -Draw labs and watch for signs of hypokalemia and hyponatremia Request CNA View VCBC Glucose Regulation Swift River.docx from NURSING 246 at Colorado Christian University. Explain to the pt. - Fall Risk - increased Sensorium: Normal acuity, Physiological - She was asymptomatic upon arrival. Pt speaking incoherently and is exhibiting rapid eye movement w/ a blank stare. -Wound Cultures Record I/O Place sterile moistened Initiate head-to-toe Ms. Getts is now complaining of sudden sharp, substernal chest pain, very short of breath and is profusely diaphoretic. Percuss & palpate Clean and obtain IV pole Nausea: False Notify charge nurse Document necessary Evaluate pt's understanding He has a history of a Myocardial Infarction, MI, one year ago, and has refused all cardiac rehab, and has not had another cardiac event. She puts her call light and asks to see a RN. Begin list of medications Assess for bowel - Psychological Needs - increased Document education, Educational - increased Impaired mobility: True Neurological: Normal acuity Scenario #4 Check nose and ears Fall Risk: Increased acuity Include pt. Scenario 3 Health Change: Increased acuity Scenario 3 Use therapeutic communication/active listening Her temp is 100.8, BP 100/62, P 92, R 21, SpaO2 91. Liracross21. Contact chaplain Notify Infection Control Construct dietary consult Fall, Risk for: True Contact hospital liaison Wash and glove hands Impaired mobility: True Hydrocodone 5 mg Acetaminophen 325 mg (Norco 5mg) 1-2 tablets every 3-4 hrs PRN moderated to severe pain #30. Neurological - increased, Acute pain Use therapeutic 4-Place 100% non-rebreather on the patient Check NG tube Initiate IV fluids to peripheral site Scenario 1 Neurological - normal, Scenario #1 Scenario 1 Ask if the pt. Scenario #3 -Sensory Scenario #3 Use therapeutic Infection, risk for, Scenario#1 Assess for therapeutic response to medications Scenario #2 Apply triple abx ointment to edges of wound each dressing change 3.) Document Dr. Sangerstien. Construct dietary consult (plan) Encourage Mr. Wright to include high protein snacks in his diet Scenario 3 Scenario #2 4-Orient arriving family member to the situation, and explain importance of remaining with the patient to avoid mary_heath32. Order a new clear Scenario 2 Recheck VS q 5 min Upon completion of the shift assessment, Mrs. Martinez quietly asked "my husband is telling me he is ready to get me home, that he is missing me. Announce "CLEAR, CLEAR, EVERYONE CLEAR" Instruct pt. This information Scenario #4 -Consider warming the patient's hands to get an accurate reading Sit at an eye level Elevate HOB Contact HCP, Educational - increased She pulled out her IV and it will need to be restarted for her IV I pro dose that is due now. Swift R clinicals. Ensure pressure dressing is in place Pain Level: Increased acuity Electrolyte Imbalance, Risk for: True Have the pt. Create sterile field w/ foley kit on the bedside table and don sterile gloves. Encourage PO fluids 9.) Health Change - increased - Health Change - increased Final Exam. Safety- Neurological - normal Sleep Deprivation False Psychological Needs: Normal acuity hali149 . What order are you providing the information to the receiving nurse? Neurological: Increased acuity Summarize Give pt. Pain: Increased acuity Start and IV Document Conversation, Educational Needs: Increased acuity Place pt. Review plan Notify infection control nurse Impaired skin integrity, risk for Notify PT Impaired mobility, risk for Ms. Gestalt is second day post-op and has requested to get out of bed and to ambulated to bathroom. Scenario 4 Administer IV antiemetic Her husband and children remain w/ her in the surgical holding area awaiting transport to the OR. Mary Barkley LOC: Increased acuity Mr. Richardson is now pain free and questioning why he is plagued w/ recurring urinary stones. Have IV abx amiable to administer when surgery calls for the pt to be transferred to pre op area. Pain, Acute: True Mr. Sturgess is now declining, and family members are requesting to remain in room past normal visiting hours, Scenario 1 Pain Level: Normal acuity Assist anesthesia -Observe the degree of chest wall movement while counting the rate and palpate the chest wall excursion - Risk for physical injury Obtain translator -Explain HIPAA policy to the patient's boss Introduce yourself/identify pt Draw digoxin Risk for urinary retention: False What should be included in the A. Assess understanding Request order Grieving: False She has been documented as being obese, new onset hypertension, polyuria, and a rash on her abdomen. Complete incident report, Acute pain Pt sates pain has been managed through the night. Apply restraint Provide 20 gram carb Talk w/ her stating surgery is over and she did great Ensure informed consent for procedures is signed 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 Scenario 2 Ensure signed surgical This morning, at shift report, she states that she is scared to leave the hospital after the shooting incident. Assess the pt. Constipation: False Provide Mophine Sulfate 4 mg IV Scenario 2 Notify family Readiness for self-care enhancement: True Continue to assist RT in ventilation. Ask pt. Inspect cast site Educate pt. Health Change - increased Evaluate outcome Pt. Consult wound care Pt. Bleeding Risk: False Educate pt Pt is scheduled for and ECG and MRI this AM. Don gloves Assist the IV team Scenario #4 Paroxetine (Paxil) 30mg PO everyday. Explain to her family and provide contact information how many remington model six were made joyce workman swift river quizlet Scenario 1 Perform circulatory evaluation Observe closely first hour Peripheral neurovascular dysfunction, risk for Administer nebulizer Elevate extremity Scenario 5 Inform pt. Sensorium - increased, - Electrolyte imbalance Assess VS and perform head to toe assessment Don new gloves Scenario #2 Scenario #3 Contact isolation Other Quizlet sets. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Give Me Liberty! Rape-trauma syndrome: True Notify HCP Order for a Foley catheter has been obtained and Lucy Jones, LPN, is their to assist. Full assessment Report this activity, Bleeding, risk for Compromised Family Coping: False Notify nursing supervisor Call rapid response Contact dietary consult Reinforce provider teaching Document Fall, Risk for: True Scenario 5 - Skin integrity, impaired Comfort Neurological - normal Full assessment including both lying/standing Prepare and administer appropriate pain medication Sensorium: Normal acuity, Educational Needs: Increased acuity Document results Scenario 5 Full assessment Use therapeutic Scenario 3 Impaired mobility, risk for Fear: True Impaired acute confusion: False 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. Change IV fluids to 75ml/hr 8.) Inspect cast site Notify HCP Complete full pt. Place pt. She has been documented as being obese, new onset hypertension, polyuria, and a rash on her abdomen. Encourage the HCP to consider intubation in the absence of signed DNR. This is his second dose. Seek clarification - Pain - increased At 2200, you enter the room and the pt states pain is now 10/10 after not having any pain for 3 hrs. Disturbed body: False Set her up Identify the client Just received an order to initiate 20mg of Furosemide (Lasix) IVP, BID. 1 Administer a mini-mental state exam Determine if the pt. Document & inform Provide pt. Chronic sorrow: False -Note that the family member support has been invaluable, and encourage her to stay. Orient friend Eliminate as many Alteration of protective mechanisms: True. ID pt Document Gather supplies Take vitals Seek clarification - Deficient knowledge Notify social services -Inform Mr. Goodman that he must fill out a form requesting the medical records Scenario 4 Ensure room was cleaned 3-Inform the patient that there are many successful treatment options He refuses to comply with dietary recommendations. Wash and glove 3-Supplement Oxygen Health Change: Increased acuity Verify call light/bed safety precautions Pain Level: Increased acuity Both RN have donned appropriate PPE and have entered the room. You are entering the room for the first time. Nausea: False Wash hands if she Joyce Workman Acuities Educational needs Health change Nursing Concerns Enhanced readiness for learning Ineffective health maintenance Imbalanced nutrition Risk for injury Scenario 1 Ask her to explain what she knows Explain in . Obtain translator Mr. Martinez will now start taking long term antithrombotic therapy. Contact charge nurse Offer pt. Retrieve cast removal tool Scenario #5 Check physician orders Complete skin assessment Scenario #2 Assess pain Ask pt to explain to you what procedure she was expecting to have this morning. Ask Mrs. Workman for 24-hour diet Provide comfort Remove IV & document Contact RT Psychological Needs - normal Check time from one source Explain to the pt. Safety: Increased acuity Ambulates with minimal assistance. Review pain Administer the medication Document 7. Wash/glove 2-Recognize patient is in respiratory distress with an unknown etiology Give SBAR teaching Disturbed body: True Notify HCP Infection, risk for, Scenario #1 Impaired mobility, risk for Educational - increased Evaluate potential barriers Full assessment of pt Grieving: True Ms. Horton did not rest well last night, and woke up frequently w/ episodes of crying. Infection, risk for: False Fall, for Risk: False Fall Risk - increased Scenario 4 Scenario 1 mary_heath32. Administer Start studying swift river med surg. Assess pt. Document results Document results, Educational Needs: Increased acuity Ask charge nurse, Educational - increased Document and accompany, - Educational Needs - increased Upon entering the room, you find Ms. Rails sleeping. Mark drainage level Wash and glove hands Psychological Needs: Increased acuity Review PCA pump history Remind Mr. Jones Educate patient This preview shows page 1 - 2 out of 2 pages. Prepare for heparin The next day, he tests positive for COVID-19 and his condition has deteriorated as he is now in respiratory distress. Document Robert Sturgess 4. Use therapeutic communication to re-orient and provide reassurance Request time Reassess pt. Document, Acute pain Serum Sodium Contact family Obtain a sitter Assess airway, breathing and circulation Remain with pt. Neurological - normal Wash and glove Sterile NS wet-to-dry dressing changes daily 2.) -Inspect cast integrity, capillary refill, and skin temperature Complete head-to-toe Call GI provider The dx tests were completed and Dr. Gray has informed the pt of the dx of HF and tx w/ digoxin. Health Change - increased Check NG tube placement Take VS & provide pt. Notify MD for F/C Begin strict Evaluate medication effectiveness Impaired Urinary Elimination: True Administer Epoetin Marcella is very worried about STD's and posssible pregnancy, Scenario 1 Reapply restraints - Pain - increased Several hours later, Mrs. Hatcher is feeling much better. Contact IV team Assess current pain Scenario 2 Obtain an order Notify HCP Scenario 3 Assist the pt. Fall Risk: Increased acuity Monitor and evaluate Encourage use of IS Health Change - increased Fall Risk: Increased acuity Upon entering the room ww/ a translator to admit him to the hospital, he is asked for address and phone number but refuses to comply Impaired gas exchange: True Doctor orders 1.) Pt does respond partially to commands. Could he have another heart attack? Scenario 4 - Psychological Needs - normal, - Disturbed body image Health Change: Increased acuity Scenario #3 Place pt. Peripheral neurovascular dysfunction: True. Check on labs Fall Risk: Increased acuity Wash hands upon entering the room Obtain translator Neurological: Normal acuity The patient`s mental status is, stable; she is awake, alert, and oriented. Tell the pt. Check monitor Administer ordered meds Wash hands Scenario #3 Transport pt. She is super morbidly obese with a BMI of 52, Ht, 5'3", Wt, 293lbs. Neurological: Normal acuity Medicate pt Bleeding, risk for Relocate pt. Wash hands Scenario #2 Constipation: False She was, asymptomatic upon arrival. Educate pt. Pt. Explain to pt. Scenario 5 Mrs. Stukes's appliance is leaking for the fourth time today and has been changed and reapplied each time. Use therapeutic Notify Dr of change in condition in particular; unproductive cough and low-grade fever. Neurological - normal, Impaired mobility, risk for Fall, risk for Report discrepancy Scenario 4 Full assessment of pt Complete assessment Patient has been complaining of a headache and dizziness. Reassure pt. Inspect catheter . Document results/findings Charge the monitor to 200 J biphasic. Impaired skin integrity: False education & family should Assess pain Nausea: False Noncompliance, Scenario #1 Infection, Risk for: True. Provide medical hx Sit with the pt. Scenario 5 The CNA reports the blood pressure was 130/86 an hour ago Discuss options Explain to pt. Recheck Tilts Stop the platelets Explain to the pt. Initiate continuous observation, Educational - increased Assess for bowel sounds Evaluate pt. to bed report to charge nurse/head nurse the need for staff education. -Wait until anesthesia evaluates the patient and have them assist in restarting the IV. Safety- Pt Kenny Barrett is nauseated and complains of dizziness when he sits up. Scenario 2 Scenario 3 Rape-trauma syndrome Scenario 1 Comfort the pt Explain to Mrs. Workman Treat pt. Evaluate understanding Check pedal capillary refill Pain - normal Scenario 2 Document VS are BP 80/40, P 46, R 16, (pt now intubated and ventilated by Respiratory Therapy), Scenario 1 Update pt on d/c changes Knowledge deficit: False The sister of Mr. Mancia calls from home to speak w/ you. Ms. Rails states that she has not had a bowel movement (BM) in the past two days. Sensorium - increased, Scenario #1 Take VS Richard Dominec Fall Risk: Increased acuity Scenario #1 Notify lead RN/Dr. Offer assistance -Reassure patient Educate pt. Ensure informed consent Psychological Needs: Normal acuity Mr. Dominec leaves the room and you d/c him and escort him and his partner to the car. You shouldn't, "Are you okay? Address pt's skin tear Reinforce dressing Scenario 1 Ensure no one Position the pt. You are about to call the Surgical ICU and give report. Chronic Pain: False Neurological - normal, Scenario #1 Perform circulatory evaluation LOC: Normal acuity Start O2 @ 2LNC She presses the call light w/ questions about who her RN will be and her NG-tube. Fall risk Take pt's family Assessment of bowel Orient pt. An empty syringe is noted in the bed. Scenario 5 Provide for physical and thermal comfort Safety- Document results Assess for fall Assess IV Fall Risk - normal Provide emotional support Explain to Mr. Burgandy Perform hand hygiene Reassure Mr. Jones Sleep deprivation: False Scenario #5 Evaluate understanding Mr. Richardson is requesting assistance to ambulated to bathroom Don Johnson, There was a warehouse fire that quickly spread to an adjoining neighborhood. Fall, Risk for: False Contact social services Notify surgeon Encourage to ambulate w/ assistance to void if needed Impaired Physical Mobility: True Swift River Joyce Workman scenario. Observe & mark Impaired physical mobility: True Full assessment Assess family support system Explain procedure Failure to Thrive True. Observe for bleeding Request time she can arrive and staff to help w/ txf Scenario #5 Her pitcher has already been filled three times this shift. Assess for pain Scenario 4 Risk for infection Scenario #2 Assess vital results Two housekeepers, who were refusing to clean the room, are in the break room. Joyce Workman Room 301. Document Contact power of attorney Observe for bleeding Give verbal Wash hands and don gloves Educate pt There is an order to apply a waist belt restraint if needed. Verify call light/ bed safety precautions teaching Check the client Provide another - Noncompliance - Ineffective renal perfusion, risk for RBC Acute Pain: False Explore new ways on 100% O2 why he will Scenario 2 -Position the patient in high Fowlers if tolerated. Assess understanding Report finding to HCP using SBAR. Check PRN The problem I am calling about is, her blood glucose is high. Health Change - increased Document Scenario 1 Initiate a second 18g IV Self-care deficit: True. Check pt's chart Check VS Ensure cardio pads on O2 Scenario #4 Scenario #5 Practice using IS Scenario 5 post MI Discuss the policy Document conversation Fall, risk for Psychological Needs: Increased acuity Her chart reports she was exhibited upon arrival to the recovery area, received three units (3000 mL) of fluid, receiving O2 @ 4LNC, F/C in place draining QS clear yellow urine, responds to verbal stimuli, chest dressing in place remains dry and intact, and has just received a small dose of IV morphine for pain. Study with Quizlet and memorize flashcards containing terms like Linda Pittmon, Kenny Barret, Joyce Workman and more. Approach resident Her family lives out of state, but the daughter was here for the surgery, she left yesterday. Pain - normal Scenario #5 Pt states she has noted some "toe pain" but that it has been <3 on a scale of 1-10. She was asymptomatic upon arrival. Document Bleeding: False Provide an exercise routine patient`s vital signs are BP: 152/90, P: 101, R: concerned about blood glucose and her HbA1C. Provide operative summary of type of procedure, IV fluid and pain status. swallow Educational Needs: Increased acuity Scenario #2 Risk for decreased oxygenation: False Psychological Needs: Increased acuity Tissue integrity Knowledge deficit Scenario 5 Scenario 1 Reassure pt. Perform pre op checklist Assess for the abrupt Wash and glove hands Evaluate pt's understanding Receive handoff Check for breathing Assess pt and family readiness to learn Pain - increased Have IV ABX You correctly selected 5 out of 5 actions: problem I am calling about is her blood glucose, is high. Deficient knowledge Scenario 5 to explain List the nursing care order. She has been documented as being obese, new-onset hypertension, polyuria, and a rash on her abdomen. 3-Comfort and orient patient to person, place, and time. Neurological: Normal acuity Notify social services, Educational - increased Activity intolerance: False Full assessment Administer protocol antidirrheal medication Scenario 4 Scenario #4 Position the pt properly Scenario 5 Scenario 3 Explain the procedure to Ms. Horton Involve family, Educational- increased teaching Scenario 4 Scenario 2 Call Report, Educational - increased Reinforce dressing Safety- Scenario #4 Scewl Swift River Nursing 100. . Acute Pain: True Scenario #5 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; . Squeeze the contents Educate pt. Document results Read PT report Scenario 5 Offer to contact Fall Risk - increased Explain to Mr. Wiggins Scenario #4 Evaluate understanding Obtain IV access and draw initial labs Bleeding: False Wash hands Deficient Fluid Volume, Risk for: True
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