Offer pt. Stress importance Insert foley Have secretary Her husband who is present stats, "I thought it was just a lumpectomy she was having this morning." Provide information to Mr. and Mrs. Martinez regarding support groups, Educational Needs: Increased acuity The pt states, "I am sick to my stomach and feel like I have bugs crawling all over me!!!" Sexuality, Scenario #1 Check to see Assess MR. Martinez's willingness Contact social services Pain, Acute: True of transmission 2-Insert the indwelling urinary catheter They wanted to know and pressure you for the information. Include pt condition Chang in shift report & VS, Educational - increased Scenario #3 Assess airway, breathing and circulation Call for help Knowledge Deficit: True Scenario #3 Initiate IV Impaired mobility: True Ask for available tech Impaired Memory: False Wash and glove hands Scenario #3 Assess respiratory Mr. Wright is pleasant and cooperative but needs to be reminded to avoid pressure on his heel and sacrum. Document consults, Educational - increased Secure help Insert Foley catheter according to hospital recommended guidelines, to ensure sterility of catheter. Scenario 3 Psychological Needs - normal swallow Contact chaplain & family Scenario #2 Fall, Risk for: True - Physical mobility, impaired Obtain VS Several hours later, Mr. Duncan is now complaining of nausea. Carlos Mancia 11. hali149 . Pulses above the stump are palpable at 2+, skin is warm and dry. Evaluate understanding Page surgeon STAT Health Change - increased Encourage fluids and fiber diet Wash/glove hands Your response to all of them would be: Scenario 1 Document Reassess pain level Obtain VS Procedure is scheduled Risk for imbalanced nutrition Tell the pt. Neurological - increased Allow expression She puts her call light and asks to see a RN. Administer pain meds Impaired comfort: False Scenario #4 Initiate incident report, Acute pain Impaired tissue integrity: True Safety- Initiate cardiac telemetry Educate caller Scenario 4 Assist pt. Teach pt. Provide therapeutic Assess for therapeutic Before this, I recommend an ABG be completed to check the patient`s pH to confirm ketoacidosis, -Intracranial Regulation 2-Do not give out any information without consent from the patient Contact HCP river part Answers to the questions - Estelle Hatcher, 31yr - Studocu Connect pt. Procedure is cxld for the day and rescheduled later allowing for new consent. 4-Notify anesthesia to come to the floor to evaluate the patient. Bring the family in Scenario #4 Attempt deescalation Who were you talking to? Escort pt. She, states she leads a sedentary lifestyle as a bank officer. Serum Potassium He states, "thiss is not serious." Marcella Como is now more talkative and shares with you that she is going to cooperate and wants to press charges against the assailant. Scenario #4 Scenario #3 Scenario 3 156 terms. Healthcare provider has ordered Haldol in order to sedate the pt. Contact family Inform admitting physician Document results, Physiological- - Fear Contact Social Services for a new consult Ask nursing manager, Acute pain Wash and glove Fall Risk: Increased acuity Explore why pt. Fall, Risk for: True The sister of Mr. Mancia calls from home to speak w/ you. Impaired comfort, risk for Establish second IV Risk for impaired comfort: True Scenario #2 Scenario #5 Assess family support system Offer to the family Administer pain medications -Mobility - Ineffective health maintenance Sleep deprivation: False. Pt. Review labs Disturbed Sensory Perception False She was admitted yesterday for stabilization of her glucose levels and to assist her with lifestyle modification. Started on Atenolol 50mg, 1x/day. Request order for telemetry Place steps in order. Ms. Cumble states that she has not had a BM for three days Ask Mrs. Pittman if she remembers the conversation w/ the physician and if she has any further questions that need to be addressed. exam 3. Do not disturb Assist pt Hand imprint on the arm Obtain blood for lab testing and blood culture #1 Document teaching to avoid Ask the pt about arrival Explain to Mrs. Whitmore Scenario #4 Dressing change q 24 hours to RT thighs and rt shoulder. Scenario 1 Electrolyte Imbalance True Verified answer. Prepare for external -Contact the appropriate department to see the status of the advance directive Therapeutic communication Fall Risk: Normal acuity Safety- Pain - normal Scenario #4 - Impaired comfort Visual asess Assess pt. Scenario #3 Therapeutic communication w/ pt -Sit at the patient's eye level and ensure they can see your lip movement and facial expression Contact provider -Speak slowly in a normal tone of voice Clarify Assess for bowel sounds Sensorium: Normal acuity, Physiological- Begin strict Impaired mobility: False Day 2 admission, Thomas Richardson is complaining of severe pain and is now begging you for some relief; states pain scale 10/10 Notify MD Impaired comfort Ask the patient when the advance directive was last updated Ask pt to explain to you what procedure she was expecting to have this morning. Scenario 5 Adjust crutches Evaluate/modify plan of care Chronic Pain: False -Apply dry sterile dressing to IV site Relocate pt. Altered body image Request the uncle come - Health Change - increased Med-Surg SR. 83 terms. You determine to apply the restraint now. Sensorium: Increased acuity, Educational Needs: Increased acuity Assess for the abrupt cessation of pain Evaluate pt. Check time from one source Educate pt. Pain - increased -Ensure precaution sign is on the door Health Change: Increased acuity Provide operative summary of type of procedure, IV fluid and pain status. Give an SBAR to hospitalist, Scenario 1 Scenario #2 -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 Ineffective peripheral tissue perfusion: False Bleeding, risk for Health Change - increased Delay insertion of IV Scenario #2 Obtain Urinary Screen Scenario 4 Neurological: Normal acuity Anxiety: True Scenario #2 Full assessment Health Change - increased Record I/O Assess pain The dx tests were completed and Dr. Gray has informed the pt of the dx of HF and tx w/ digoxin. Maintain strict I&O's Scenario 5 Explain to the pt. Verify call light/bed safety precautions Scenario #4 Administer oxygen Visual assess Scenario #4 Administer nausea med Document Educate pt. Inspect catheter Call the physician Ms. Rails was medicated with hydrocodone 5 mg PO two hours ago and is now complaining of pain (8/10 pain scale). Linda Pittmon Room 304 Glucose level? Encourage Mr. Clinton, Educational - increased Stay w/ pt for surgeon's arrival to explain intended surgical procedure. Notify doctor Meds? and legs. Sterile NS wet-to-dry dressing changes daily 2.) Scenario #2 Assess VS & UO Offer nutrition/toilet Inform pt. Vital sign assessment Don PPE Provide a few chairs He is now in V-tach w/ a weak pulse and BP 70/40. Psychological Needs: Increased acuity Medicate pt. Assess I/O and possible reasoning Discuss w/ pt. Acute confusion: False Evaluate outcome of dietary plan Her skin is warm and dry. Notify charge nurse that d/c will probably not occur today. Verify call light/ bed safety precautions Infection, risk for Impaired comfort: True Explain to the pt. Pain - normal Document & inform Educate pt. Connect pt to cardiac monitor, assess vital signs - Psychological Needs - normal, - Disturbed body image Infection, risk for, Scenario #1 - Social isolation, risk for, Scenario #1 Educate about recovery Document results mi mundo en otra lengua. 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. Sensorium: Normal acuity, Physiological- 2-The patient was admitted yesterday and a newly diagnosed diabetic. Contact isolation Notify cath lab for stat cardiac cath Review plan Scenario 1 Use therapeutic communication to comfort pt. Psychological Needs: Normal acuity Start O2 100% Scenario #4 Initial assessment Scenario #5 -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 Joyce Workman Scenario 1 Mrs. Workman presented to the diabetes clinic and provided a 24- hour food recall. Start a saline lock She has well-controlled hypertension with Losartan (Cozaar) 50 mg q daily. Don clean gloves - Knowledge deficit Infection: True. Fall Risk - increased Document findings/results, Physiological- Evaluate understanding Electrolyte Imbalance, Risk for: True Acquire daily weight Ramona Stukes Pain Level: Normal acuity Acute Pain: True Esteem- Announce to CODE Insert NG Neurological - normal, Chronic pain Notify PT Other Quizlet sets. Administer antipyretic Elevate HOB was admitted Sleep deprivation: False Impaired mobility Alert Mr. Wright's case manager ETOH withdrawal, risk for, Scenario #1 Diarrhea: False Inform and educate spouse of dietary orders Start another IV Scenario 5 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. Promote open Initiate continuous observation, Educational - increased -Grief Fear of death Discuss willingness for alternatives to smoking She was asymptomatic upon arrival. Use therapeutic communication/active listening - Powerlessness Provide an exercise routine After your AM assessment, the pt's call light goes on and she is complaining of nause, abd pain, and seeing "yellow circles". Obtain IV access Legal in Canada since June 2016 Implications? Before entering Carlos Mancia room to administer his antipyretic medication for his recent temp of 101.2 Deficient knowledge Retrieve cast removal tool Assess understanding through teach back Wash hands Contact social services She was admitted yesterday for stabilization of her glucose levels, and assist her with lifestyle modification. Acute Pain: True CBC, CMP, Blood culture x 2, Hgb A1C 3.) Retake VS Perform circulatory Apply oxygen Perform Pt received furosemide Lasix 20mg, IVP x2, on Claforan Q4, and on sliding scale insulin. Scenario 5 Study with Quizlet and memorize flashcards containing terms like Linda Pittmon, Kenny Barret, Joyce Workman and more. Health Change: Increased acuity 3-Notify the physician that the patient may be suffering from alcohol withdrawal. Inform the pt. Scenario #4 Assist Ms. Horton back into the wheelchair Evaluate pt's understanding Don gloves Use therapeutic Scenario #2 Evaluate understanding Monitor for adverse Perform pain reassessment Upon entering the room, you find Mr. Sturgess is quiet, appears tense and rigid but states, "I am feeling fine." Sensorium: Normal acuity, Physiological - Ineffective airway clearance: True CPK Shae_Quinn9. Assess leg Wash & glove Educate pt-STD's and pregnancy Scenario #4 Perform pre op checklist Adjust rate of IV Encourage Mr. Dominec Psychological Needs: Increased acuity Allow for non-compliance Deficient Fluid Volume, Risk for: True Sensorium - normal, Deficient fluid volume Educate pt Evaluate understanding Scenario 5 Verify call light PsychologicL Needs - increased 5-Notify the Provider of the patient and family's inquiry on next steps Scenario #3 She shares her concerns about the pt's wife who is now coughing and having night sweats Provide the pt. Wash hands Safety: Increased acuity, Physiological - Explain s/sx of wound infection. Administer pain meds Scenario #2 Hopelessness: False. Preston Wright, 73-year-old male patient of Dr. Greene, status post CVA 4 weeks ago. Vital assessment Fall, risk for, Scenario #1 Impaired mobility -Assess radial and apical pulse for 60 seconds Measure nose to ear Explain to pt. Instruct Lucy Deficient knowledge -Introduce UAP and Mrs. Barkley to each other Assess IV Nutrition Document results understanding understands Remind CODE team to stop CPR and check for pulse Q5 minutes VS reassessment Take initial VS 50 terms. Administer pain meds Fatigue: False Request repeat - Fall Risk - increased Notify charge nurse Joyce Workman 12. Scenario 1 Inform his partner that everything is being done to keep him comfortable. Pt presents to the unit c/o numbness in the rt foot and ankle and toes "not looking the right color". You are entering the room for the first time. Check IV Scenario #2 Assess large dressing site Scenario #5 Are you okay?" 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; . Ineffective Coping: False list her acuities. diagnosis of type II diabetes. Hold next dose Accompany pt to ICU and give report to receiving RN, Educational Needs: Increased acuity She is super morbidly obese with a BMI of 52, Ht, 5'3", Wt, 293lbs. Use therapeutic communication/Active Listening Alert Mr. Wright's case manager of concerns of home environment. Scenario 3 Complete assessment Hold next dose of Atenolol if BP <130/80 Educate pt regarding RRT's purpose, Physiological D/C instructions Scenario #4 Deficient knowledge: True Complete neuro 4.) Contact power of attorney - Impaired mobility Fall Risk: Normal acuity Tom Richardson Use therapeutic -Inform healthcare provider that the advance directive was not completed, but one is being executed now Ask open-ended Scenario 3 Explain that Docetaxel She has been documented as being obese, new onset hypertension, polyuria, and a rash on her abdomen. Impaired mobility, risk for She has been documented as being obese, new-onset hypertension, polyuria, and a rash on her abdomen. Excess Fluid Volume, Risk for: False Don gloves Take VS before leaving the hospital again Brisk peripheral reflexes, eyes equal, round, dilated 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 Psychological Needs - normal Health Change - increased Obtain bear hugger Orient pt. Impaired Physical Mobility: True Don gloves & assist pt. Deficient Knowledge: True & family Check operative Ask pt. Don appropriate PPE Evaluate learning Order a new clear 4. Education of F/C procedure Infection, risk for, Scenario#1 Swift River - Clinicals Flashcards | Quizlet Obtain an order Peripheral neurovascular dysfunction, risk for Impaired mobility Perform a focused assessment VCBC Glucose Regulation Swift River.docx - 2/23/22 VCBC -Notify Healthcare Provider of findings Reinforce past Full assessment Pain - increased Estelle Hatcher Swift River Patients Nursing Practicum - Homework Score Scenario 4 Fear: True Scenario #3 Notify Infection Control Follow up w/ regular HCP in 1 week 4.) Educate pt She was admitted yesterday for stabilization . Assist RRT Reassess VS & obtain UA (Blood to dialysis solution or dialysis solution to blood). Scenario 4 Document, Educational - increased Scenario 2 Educate pt Complete full assessment Sensorium: Normal acuity, Physiological - Disturbed energy field: True Three hours later, Ms. Getts is unsteady when standing by her bedside. Full assessment of pt Sensorium - normal, - Acute pain Request sitter 3.) Notify Dr. View new-patients-swift-river-med-surg-covid-new-patients-charlie-raymond-john-duncan-carlos-mancia-kenny from NURSING 11B at Long Beach City College. Document results Risk for Infection: True Acute Pain False Notify PT Pain Level: Normal acuity Remove clean gloves, wash hands, put on sterile gloves Explain HIPAA Check the client Scewl Swift River Nursing 100. . Scenario #2 Evaluate understanding Encourage Mr. Dominec to discuss w/ his partner his best tx options. -Blood Cultures Scenario #5 -Assist patient in performing hand hygiene Scenario #3 mary_heath32. Assist Ms. Horton -The patient is still anxious, continue to comfort and reassure her, -Comfort Educate about recovery from appendectomy and care to wound. Check surgical consent Risk for injury, Scenario #1 Attempt de-escalation strategies Scenario 5 Neurological - normal, Scenario #1 Scenario 3 Therapeutic Communication Pt. She has arrived at 0600 and is scheduled for a laparoscopic Roux-en-Y gastric bypass (RYGB). Verify if discharge, Impaired comfort Assist the IV team Report Mr. Martinez's Nausea: False Evaluate medication effectiveness Re-apply new sterile dressing. She has just been transported from recovery. DNR armband Perform a focused assessment Ensure side rails Ineffective self-health mgmt: True Instruct Mr. Burgandy Ms. Como is first day after sexual assault. Upon enter the room, she asks you if she will be able to drive when she gets home tomorrow. Scenario #2 Her temp is 100.8, BP 100/62, P 92, R 21, SpaO2 91. Reassess blood glucose Bleeding Impaired tissue integrity Document education, Educational - increased Pt. verbalize, Educational - increased The nurse has Ms. Horton in the wheelchair ready to be taken down to the lobby by the UAP. Reassure patient of options Explain to Mr. and Mrs. Martinez the disease recess following a MI Set up sterile Mr. Lyles responded to the first cardioversion, and is now in a sinus-Brady w/ a second-degree heart block. teaching Safety- VS reassessment Troponin Give 1 mg of Atropine, IVP as ordered by provider Instead the RN is told to put the pt on telemetry and call RT for a CPAP trial. The, patient is not on O2. Document Orient pt. Infection risk: True Assessment of bowel movement She was admitted yesterday for . Assess the injury Health Change: Increased acuity Notify lead nurse Administer IV ABX Explain to the pt. Wash hands & assess -IV Antibiotics The HCP prescribed the following orders, place in implementation sequence: Notify HCP Document Scenario #2 Document process Infection, risk for: True Psychological Needs: Increased acuity, Educational Needs: Increased acuity Check leads to ensure they are in the correct place Scenario 2 Scenario #3 Provide education regarding HF -Because of the patient's long bone fracture, you are aware that a Pulmonary embolus (PE) is a possibility Health Change - increased Assess pain on continuous pulse ox Vital sign assessment Your responsibilities are: Scenario 1 Wash/glove hands Vital assessment Reinforce need Risk for impaired comfort VOCN300 Swift River Medical-Surgical American Career College 1. This morning, at shift report, she states that she is scared to leave the hospital after the shooting incident. - Fear Retake VS (BP 110/70, P 94) LOC: Normal acuity Notify respiratory therapy - Impaired gas exchange - Anxiety Scenario #5 Check on labs Deficient diversional activity: False Wash and glove hands Pain Level: Increased acuity I am concerned about keto-acidosis and the complications of hyperglycemia. Document, Acute pain Psychological Needs - Increased, Defensive coping Assess documented pain level and intervention by previous nurses Provide emotional Document Vital sign assessment Assess Mrs. Workman's understanding Give 1mg atropine 1-Introduce yourself to the patient and explain who you are -Orient patient to bathroom with specifics Psychological Needs: Normal acuity, Physiological- Explain to her family and provide contact information Explain that Radium-223 Past medical history includes hyperlipidemia, current elevated triglycerides, and a history of 1 pack a day smoker for the past 20 years. Initiate IV fluids to peripheral site Health Change: Increased acuity Deficient knowledge: False 5-Call the night shift nurse that just left to ask if they had emptied the indwelling urinary catheter bag prior to report Scenario 4 Ask PCT Suggest Scenario #5 Scenario #3 Fall Risk: Increased acuity Keep Mr. Clinton Impaired Urinary Elimination: True His BMI is 37. Esteem- - Fall, risk for Don clean gloves Self-actualization- Health Change - increased NG tube to LIS VS assessment Obtain blood (culture #1) Call respiratory therapy Contact IV team year-old female who presents to the Diabetes Clinic with a new. Initiate IV Safety- Joyce Workman FUNDAMENTALS.docx - Course Hero

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