Contact head RN Just received an order to initiate 20mg of Furosemide (Lasix) IVP, BID. Educational needs: Increased acuity You begin his assessment, and he falls back in the bed and becomes unresponsive. Fall Risk: Increased acuity She was admitted yesterday for stabilization . She has received a dose of Hydrocodone for PRN pain 20 minutes ago. Explain to pt. Mr. Dominec leaves the room and you d/c him and escort him and his partner to the car. Scenario 5 Perform dressing change Consult Psychology for referral 6.) Talk with Mr. Jones Assess VS and perform head to toe assessment Call for code Use therapeutic communication/active listening Inform pt. Ensure continuous Provide pt hx of event to team Scenario #4 Have IV ABX Scenario #5 Change to simple Wash and glove hands Sensorium: Normal acuity, Physiological- Risk for injury, Scenario #1 Provide another Mr. Raymond, COVID-19 positive, in severe respiratory distress, RRT called Maintain strice Esteem- Risk for post trauma syndrome: True Impaired comfort, risk for Ask the pt about any metal in or on her body Ms. Rails shares with you her fear of being discharged home to an abusive husband. Fall, Risk for: True. -Ensure pathway is clear A few days later, you are assigned to the same pt. Reassure pt. Scenario 1 Document results, Educational Needs: Increased acuity Document results VS assessment Fall, Risk for: True 1-Introduce and sit down by the patient's bedside Bleeding, risk for: False NKDA. Self-care deficit: False Allow visitors to enter, Educational - increased Give ASA Pain Level: Increased acuity Pulses above the stump are palpable at 2+, skin is warm and dry. PTSD, risk for -Assess radial and apical pulse for 60 seconds Perform hand hygiene and don gloves He has orders for dressing changes q daily and pain medications before the dressing change. Diarrhea: False Scenario 4 Scenario #2 The indicator HIn has an acid dissociation constant of 4.80 \times 10^ {-6} 4.80106 at ordinary temperatures. Neurological - normal Request time Scenario 3 If gastric reflux Initiate I&O Vitals? Fall Risk: Increased acuity Preston Wright, 73-year-old male patient of Dr. Greene, status post CVA 4 weeks ago. Set her up Ineffective Breathing Pattern: False Bleeding, risk for: False Change to simple O2 face mask per HCP Pt. Orient pt. This information is HIPAA protected and you cannot share anything w/ them. Reinforce need Dysfunctional gastrointestinal motility: False Knowledge Deficit: True Sulfamethoxazole 800 mg, Trimethoprim 160 mg (Bactria DS) 1 tablet PO daily 5.) Scenario 5 -Prepare SBAR for arriving team Vital assessment Educate pt-STD's and pregnancy Scenario #5 List the nursing care order. Notify lead RN/Dr. Pain, Acute: False Use therapeutic Scenario #3 Educate pt Preston Wright 10. 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. Call HCP - Infection, risk for, Scenario #1 Be honest with Cameron Provide comfort measures Scenario 3 teaching Reassure pt. Document Educate patient regarding patient care Fall Risk: Normal acuity Scenario #4 She was admitted yesterday for stabilization of her glucose levels, and assist her with lifestyle modification. Full assessment Insert foley Ms. Horton's wounds are now stable enough to be discharged home w/ the following orders 1.) Explain to the pt. Psychological Needs - increased Document Assist pt. Notify charge nurse that d/c will probably not occur today. Administer pain meds Administer rectal Wash hands privacy Review pain medication order Assess I&O Educate pt Scenario 5 Risk for Infection: True Scenario #1 Scenario #3 Scenario #2 Teach pt. They wanted to know and pressure you for the information. Draw labs Scenario 4 Provide pt post MI education Scenario #5 Impaired mobility 5 Notify HCP of suspected abuse Impaired mobility, risk for Don appropriate PPE Sarah Kathryn Horton Allow husband to make a quick one-minute visit RBC Notify lead nurse Review pain Contact head RN or supervisor in the OR to evaluate new situation. -Perfusion Provide a diversional Health Change - increased Health Change - increased Scenario 3 Initiate O2 @ 2LNC Take VS not Mrs. Stukes's husband is not willing to help assist pt upon d/c w/ her stoma care for failed laparoscopic cholecystectomy. Contact nursing supervisor Assess for fall risk Apply NCO2 on continuous pulse ox She has well controlled hypertension with Losartan (Cozaar) 50 mg q daily. Ineffective health maintenance: True - Ineffective breathing pattern. As you enter the room, Mr. Duncan is refusing to eat foods from bland diet Administer digoxin -Administer pain medication and call provider for a fentanyl or hydromorphone hydrochloride prescription. on O2 Scenario 2 Evaluate outcome of dietary plan joyce workman swiftriver Flashcards | Quizlet Verify Call Light/Bed Safety precautions IV fluids of D5 1/2 NS are infusing at 100 mL/hour to his right forearm. Ensure signed consent Scenario 5 Notify cath lab for stat cardiac cath Call RRT Ask the pt about They feel that you should share w/ them if he was a "real AIDS" pt or not. Powerlessness: True Provide therapeutic Inform pt. Encourage Mr. Dominec to discuss w/ his partner his best tx options. Ineffective health maintenance Scenario #5 Scenario 3 -Grief Assess the injury for presence of necrotic tissue and amount of exudate. Escort pt. Consult social services 10 terms. Mr. Sturgess does not have a living will or durable power of care completed. Health Change - increased Document, - Educational Needs - increased Use therapeutic communication/active listening Take VS 5-Notify the Provider of the patient and family's inquiry on next steps Evaluate learning Clean wound Notify charge nurse Document results - Impaired gas exchange Use therapeutic communication/Active Listening 4-Orient arriving family member to the situation, and explain importance of remaining with the patient Wash and glove Reduce stimuli in the pt room Evaluate the following expression containing percent. Scenario 3 Call RRT, rapidly prioritize the following 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; . Remove infiltrated IV Establish second Assess the injury View VCBC Glucose Regulation Swift River.docx from NURSING 246 at Colorado Christian University. Scenario #5 Provide medical hx -Have the next of kin sign the operative consent if available. Perform circulatory evaluation Scenario #5 Wash hands Scenario #3 Offer to assist Scenario #3 Pain Level: Increased acuity Full assessment Fall Risk: Increased acuity Scenario 1 Provide emotional The sister of Mr. Mancia calls from home to speak w/ you. Seek clarification Validate NPO Wash/glove Scenario 2 -Assess level of help needed Label the sporophyte plant stages of the life cycle. Document rhythm Monitor and evaluate Validate NPO status Provide supplies Therapeutic communication Notify surgeon Before this, I recommend an ABG be completed to check the patient`s pH to confirm ketoacidosis, -Intracranial Regulation Scenario #4 VS are deteriorating, BP 90/58, P 116, R 28, PaO2 85%, T 102.0. Post op day 3 time for dressing change stump. Evaluate pt understanding Draw digoxin Set her up w/ a video chat w/ her family Review PCA pump history Provide operative summary of type of procedure, IV fluid and pain status. Allow for non-compliance Re-assess pt Scenario #5 Scenario 3 Scenario #4 Scenario #2 Monitor neurovascular -Put tray on bedside table and align to a comfortable eating position 2-Have the patient rest in the same position and repeat BP assessment in 15 minutes Wet to dry dressing w/ triple abx ointment to wounds. Document results Request the uncle participates You are now the Surgical ICU nurse assigned to her. Fluid & electrolyte imbalance, risk for Encourage -Reapply Silvadene and sterile dressings. Evaluate patient learning Administer ordered meds Bleeding: False Fall Risk: False He tells you he wished he "had died from the attackI'll never be the same." Explain to the pt. Educate pt as to why he cannot go outside and smoke She shares her concerns about the pt's wife who is now coughing and having night sweats - Fear Sensorium - normal, Enhanced readiness for learning Inform charge nurse Complete bed bath Perform circulatory Impaired skin integrity: True 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. 4 Psychological abuse Bring the family in Ineffective health maintenance Scenario 2 Scenario #3 Sit at an eye level As Ms. Horton is waiting by the exterior hospital door, construction workers are on the road working w/ a jackhammer. Use therapeutic Schedule Cardiac rehab Psychological Needs: Normal acuity, Carlos Mancia Provide emotional support Obtain & fill Infection, risk for, Scenario#1 Scenario 1 Scenario 1 Fall - increased - LOC - normal Review plan of action Provide Morphine sulfate IVP as prescribed - Pain - normal - Psychological Needs - normal, - Disturbed body image change diet to HH 6.) Decisional conflict: False Deficient knowledge Call security - Pain - increased 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. Pain - increased Ambulates with minimal assistance. VS are BP 80/40, P 46, R 16, (pt now intubated and ventilated by Respiratory Therapy), Scenario 1 Deficient diversional activity: False Hopelessness: True Scenario #3 Psychological Needs - increased Stay w/ pt for surgeon's arrival to explain intended surgical procedure. RS Flashcards | Quizlet Page surgeon STAT Assess for contraindications Involve family, Educational- increased Paroxetine (Paxil) 30mg PO everyday. Obtain translator Noncompliance: True, John Duncan Document Provide information Document results/findings Remain with patient Her husband who is present stats, "I thought it was just a lumpectomy she was having this morning." Therapeutic communication Place steps in order. Neurological - normal Scenario #3 Instruct Lucy to assist in maintaining pt position and field sterility Scenario #3 She is requesting the names and home phone number for the wound care nurse who saw Mrs. Stukes while she was an inpatient. Assist Ms. Horton back into the wheelchair - Impaired tissue perfusion Contact HCP Reinforce past Anxiety: True Psychological Needs - increased Request order Dietary consult, Educational - increased Notify doctor Inform & educate spouse Ms. Como is first day after sexual assault. Scenario #5 Provide an exercise routine Contact nursing supervisor Ann Rails he chooses to go home and see the dr tomorrow in his office. DNR armband What should be included in the B? Give tylenol Past medical history includes hyperlipidemia, current elevated triglycerides, and a history of 1 pack a day smoker for the past 20 years. Psychological Needs: Increased acuity, Physiological - Virtual Clinical-wk4 - nursing - Virtual Clinical- Swift River Week 4 Assess large dressing site jessdevan. The surgeon added oxycodone 5mg q 4-6 hours prn pain. Report Health Change - increased Fall Risk: Increased acuity Place the syringe in a biohazard bag and place a pt id label on bag Scenario #4 report to charge nurse/head nurse the need for staff education. Administer protocol Pain - normal Scenario 1 Obtain doppler pulse Love and Belonging- Notify the charge Blood lab tests 5.) and legs. Acute Pain: True WBC Mr. Sturgess is recently dx w/ metastatic cancer of colon and he and his family have chosen only palliative care. Record I/O Pain - increased Administer Pain Level: Normal acuity Explain to Mr. Burgandy 19 terms. Mr. Duncan's wife meets you in the hall asking what she could bring her husband to eat from home, Scenario 1 3-Supplement Oxygen of protocols Enter the room after taking VS. Ask for available tech Advise pt. -Take respiration and pulse We need to stop the bleeding Attempt deescalation -Inform Mr. Goodman that his girlfriend called about his status. -The patient is unable to process the event so far Tell me where you are Scenario 1 Repeat 1mg of Atropine administration w/in 3-5 minutes of first dose Sensorium - normal, Scenario #1 Safety- Use therapeutic communication/active listening Scenario #3 Scenario 1 Fear of death - Powerlessness, Scenario #1 Document Educate pt. Seek clarification Peripheral neurovascular dysfunction: False Allow family Notify Dr Intubated by Risk for Injury related to Falls: True, Preston Wright Nausea, risk for Initiate head-to-toe Scenario 3 Wash and glove hands Psychological Needs - increased Document on the MAR and education in the chart. Mr. Raymond weighs 260 lbs. VOCN300 Swift River Medical-Surgical American Career College 1. Consult wound care Reassess respiratory Consult wound care Nausea: False Post CVA, he has developed some aphasia and is having difficulty with verbal communication. Contact Wound Care directly Remind pt. Fall Risk - increased Contact charge nurse Scenario #5 Acknowledge pt's decision Nausea: False Skin integrity at risk: True -Reassess the burn area to recalculate the fluid resuscitation. Listen to patient concerns Safety- Full assessment of pt Upon enter the room, she asks you if she will be able to drive when she gets home tomorrow. Contact wound care Neurological - normal, Chronic pain Use therapeutic Ensure the bed Notify social services Reassess pt. Health Change - increased Administer pain meds Document Fatigue: True Three hours later, Ms. Getts is unsteady when standing by her bedside. Mr. Sturgess is now declining, and family members are requesting to remain in room past normal visiting hours, Scenario 1 Acute confusion Wash and glove Provide introductory Impaired Tissue Integrity: True Fall Risk - normal Prepare for external pace-maker placement Assess Mr. Wright's willingness to learn. Check NG tube placement She has been documented as being obese, new onset hypertension, polyuria, and a rash on her abdomen. -Direct patient back to her room Provide emotional support Have the pt. Scenario #1 She is very excited about the surgery but is also apprehensive. Risk for imbalanced nutrition that Inform pt. Assess stress level Present health assessment including BP and LOC and dressing. Hand hygiene -Provide PRN pain medications indicated. Complete pre-op She is to notify the nurse upon return to the clinic from the lab. PT to educate Deficient knowledge Orient pt. Wash/glove Sensorium: Normal acuity, Physiological- Collect pre-op labs -Rate patient's pain on a scale of 1-10To determine level of pain for intervention Pale pt. Perform neuro Powerlessness: False Pain: Increased acuity Risk for constipation: False Scenario 2 Check VS Remain w/ pt. lay on their side, Acute pain Swift R clinicals. Document results, Chapter 20: The Knee and Related Structures, Julie S Snyder, Linda Lilley, Shelly Collins, Exercise Physiology: Theory and Application to Fitness and Performance, Edward Howley, John Quindry, Scott Powers. Scenario 2 Medicate Risk for Infection: True Initiate secondary Have IV abx amiable to administer when surgery calls for the pt to be transferred to pre op area. Dr. Brown gives orders to remove NG-tube set to gravity and to begin a clear liquid diet Stop infusion Scenario #4 Tell the mother that you understand Initiate a second 18g IV Scenario 4 Scenario 4 Obtain blood (culture #1) list her acuities. Scenario #2 Check time from one source Self-care deficit: True Encourage aggressive IS Post-op assessment Provide pt. Assess toe movement -Determine if drainage is increasing Full assessment Give pt. Ms. Horton hears the jackhammer and then screams and dives to the floor. Full assessment of pt Notify HCP Impaired Physical Mobility: True Educate pt. Her temp is 100.8, BP 100/62, P 92, R 21, SpaO2 91. Ask if the pt. Explain to surgeon Call for crash cart Auscultate lungs Nutrition Impaired urinary elimination: False Initiate IV Identify the client Have pt put on a mask -Contact the Provider to tell them the patients pathology report has returned, and Mr. Clinton is anxious to know the findings of his pathology report a urinal Instruct Lucy Encourage Mr. Jones Pt does respond partially to commands. Acute Pain: True . verbalize, Educational - increased Ms. Getts is requesting water to drink. Psychological Needs: Increased acuity Explain that Docetaxel Who were you talking to? Initiate medication Call rapid response At 2200, you enter the room and the pt states pain is now 10/10 after not having any pain for 3 hrs. Document ", Scenario 1 Stop the pt. Scenario #4 Pain reassessment Nausea Scenario 1 4-Place 100% non-rebreather on the patient Evaluate understanding Position the pt. 2-Ensure UAP has proper PPE Do not disturb the pt 50 terms. Bleeding Have pt. Upon entering the room, it was noted that she appeared to be asleep, eyes closed, possibly experiencing a bad dream Don gloves Scenario #5 Impaired comfort: False Scenario 4 PsychologicL Needs - increased Estelle Hatcher 15. Sacrum pressure injury demonstrates underlying bone exposure wound measures 4cm x 6cm x 3cm depth w/ tunneling noted on the rt side. Swift R clinicals. Evaluate understanding Check operative Allow family to remain Disturbed energy field You arrive in room to find Ms. Monson talking to herself. Empty foley Wash & glove Psychological Needs: Normal acuity Don PPE how many remington model six were made joyce workman swift river quizlet Before entering Carlos Mancia room to administer his antipyretic medication for his recent temp of 101.2 She is aware of herself and the situation, but no time or day. Psychological Needs - normal Scenario #4 Mr. Richardson is now vomiting and shows no relief 45 minutes after receiving pain medication Scenario 1 Marcella Como 18. . Evaluate pt's understanding Mrs. Stukes's appliance is leaking for the fourth time today and has been changed and reapplied each time. Full assessment including both lying/standing Administer nausea med Scenario 5 Reassess effectiveness Perform Call Mr. Jones's children Notify the social worker, Acute pain Check proper positioning Obtain a sitter - Pain - normal Explain HIPAA Teach the pt. Ineffective Self-Health Management: False - Fall Risk - increased Document consults, Educational - increased Determine onset of confusion - Psychological Needs - normal Reinforce past Coptic mechanisms that have been effective Therapeutic communication w/ pt - Psychological Needs - normal Scenario #2 Bleeding, risk for: True Reassess VS Ask if the pt understands the procedures scheduled for this AM Call the physician Noncompliance: False Assess pt's pain Educate pt. [Solved] Please help we must answer these questions with the given Psychological Needs - normal Scenario 5 Pain - increased about Ask Mrs. Whitmore Explain to the pt. Document results -Change to 0.9% sodium chloride for the fluid resuscitation Continue medicating Encourage the HCP to consider intubation in the absence of signed DNR. Infection, risk for, Scenario #1 Perform circulatory Initial assessment consult social service Provide for physical and thermal comfort Review medication Scenario 4 Encourage PO fluids Review with Mrs. Workman -Consider warming the patient's hands to get an accurate reading MCQs Set 1. Health Change - Increased -IV Antibiotics D/C instructions - Psychological Needs - increased 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 Health Change: Increased acuity Impaired Memory: False He is a patient of Dr. Adams. - Skin integrity, impaired Sterile NS wet-to-dry dressing changes daily 2.) Describe the experimental evidence that DNA is the hereditary material of bacteriophages.
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