Report suspicion of abuse to adult protective services Scenario 5 VS are BP 128/82, P 90, R 22, T 99.2, Scenario 1 Use therapeutic Document results Sleep deprivation: False The. Document results, Educational Needs: Increased acuity Scenario 4 What should be included in the S? Joyce Workman, Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Notify Dr of change in condition in particular; unproductive cough and low-grade fever. Insert NG The rt heel demonstrates a blister 2cm x 1cm w/ clear fluid noted. Follow HIPAA Instruct pt. Summarize Pain Level: Increased acuity Psychological Needs - normal Present health assessment Contact social services Notify physician Infection, risk for: False Inspect pain location Complete incidence report, Educational - increased Do not disturb Reassess blood glucose - Deficient knowledge Document results Assess leg Reemphasize to pt. Scenario #1 She was admitted yesterday for . Scenario 3 5-Take an axillary temperature with the blue electronic thermometer Remove old dressing Scenario 2 Provide education regarding HF Sarah Kathryn Horton 13. Obtain Spanish signs and brochure Ensure pressure dressing 4-Offer to assist in completing an advance directive Impaired Memory: False Right after admission the nurse finds her walking down the hall trying to leave. Acquire daily weight and legs. Attempt to restart IV Scenario 5 Position the pt. Scenario 2 Auscultate lungs Infection, Risk for: True. Mr. Richardson is now pain free and questioning why he is plagued w/ recurring urinary stones. Give 1L NS Request the uncle come Review pain Inform pt. Educate pt. Scenario 4 Acute Pain: False Impaired mobility: True Ineffective Renal Perfusion, Risk for True teaching Mr. Martinez will now start taking long term antithrombotic therapy. Explain that Radium-223 Scenario 5 Document all findings Reassess pt. Neurological - normal There is an order to apply a waist belt restraint if needed. Health Change - increased Initiate IV Initiate I&O Deficient knowledge: False Announce, "CLEAR Verify call light Inform his partner Set up sterile to apply A few days later, you are assigned to the same pt. - Impaired tissue integrity SOLUTION: Dotty hamilton swiftriver docx - Studypool Hypothermia: False Document His HbgA1c is 10.6%. Scenario #3 Assess for fall risk Document Sulfamethoxazole 800mg, Trimethoprim 160mg (Bactria DS) 1 tablet PO daily for 10 days 5.) Administer new Document, Educational - increased Apply oxygen Esteem - Use therapeutic Ineffective health maintenance: True Asses Mr. Wright's willingness Check I/O for possible dehydration 4.) Ms. Getts is being transferred as an emergency to Critical Care. Complete neuro Explain to pt. Check nose and ears Document results She has been documented as being obese, new onset hypertension, polyuria, and a rash on her abdomen. Allow husband - Health Change - increased Scenario #3 -Wait until anesthesia evaluates the patient and have them assist in restarting the IV. Sensorium: Increased acuity, Physiological- Scenario 4 Allow pt. Health Change - increased Constipation: False Assess pt. - Fall, risk for, Scenario #1 post MI Several hours later, Mrs. Hatcher is feeling much better. She has been documented as being obese, new-onset hypertension, polyuria, and a rash on her abdomen. 8 hrs later, pt is fidgety and is observed picking at her skin and clothes. Scenario 2 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 Assess vital results LOC: Normal acuity Scenario #3 Contact HCP, Educational - increased -Inform students that it is inappropriate to discuss relationships that you have had with patients. Restate or paraphrase pt statements -Reassess the burn area to recalculate the fluid resuscitation. Wash hands upon entering the room Place call light and check bed for safety Ineffective Breathing Pattern: False Collect supplies Elevate stump, - Educational - increased Complete neuro Fall, risk for Perform hand hygiene Initiate IS treatment -Ensure pathway is clear Pain Level: Normal acuity Health Change - increased Esteem- Scenario 2 Assess documented pain Stress importance Safety- Wash & glove Put on gown and mask Begin continuous chest-compressions until help arrives Scenario 4 Educate pt. Scenario #2 Scenario #3 Kathy Gestalt Report and document results Remove NG Obtain translator Measure wound size Love and Belonging- Reassess BP & P Contact RT Discuss options Request order Gas exchange, risk for Neurological - normal Explain rationales Make sure O2 mask is secure and free of sputum. 7. Scenario #5 Observe & mark Vital signs are Temp 98.9F, BP 178/90, P 88, RR 18 SaO2 95% on Room air. Fatigue: True Ms. Getts is requesting water to drink. Request repeat Fall Risk - normal Reassess pain Evaluate caller understanding Encourage fluids/fiber/ambulation Document, Physiological Obtain informed consent for cardiac cath Assess Ms. Horton's orientation status Final Exam. Swift River- Community Health. Impaired Mobility, Risk for: True Asses for mediastinal shift Notify surgeon She receives the pre-op medication. Evaluate learning After 3 hours Ms. Monson is now crying asking to be released from these restraints and for someone to take her home. Scenario 5 Carlos Mancia 11. Administer antipyretic medication Complete full assessment Impaired mobility Ramona Stukes 17. Request the uncle participates Percuss & palpate Scenario #5 Provide the pt. Complete full assessment Peripheral neurovascular dysfunction: False Document Safety- Upon entering the room, you find Ms. Rails sleeping. I am concerned about keto-acidosis and, I am calling about Joyce Workman. Concepts of Nursing IV 100% (2) Deanna Concept Map Assignment 1. Self-care deficit: False Notify RRT Have IV abx amiable to administer when surgery calls for the pt to be transferred to pre op area. Impaired comfort: True Document and provide copy for Mr. Dominec to share w/ his follow up appointment tomorrow. 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. Scenario 1 Elevate stump and reward w/ a dry clean dressing. Assess extremity Deficient knowledge Offer nutrition and/or toileting Preston Wright 10. - Impaired gas exchange Scenario 3 Scenario 3 Scenario 3 Assess I&O Wash and glove Obtain additional support Document teaching She has well controlled hypertension with Losartan (Cozaar) 50 mg q daily. about Provide pt hx of event to team Powerlessness: True Provide pt. Educate Ms. Horton Reinforce past Insert new IV Ask charge nurse, Educational - increased He states, "thiss is not serious." - Psychological Needs - increased, - Acute pain Explain that he will probably not be going home at least until his Dr. sees him Fall Risk - increased Impaired Communication: False Notify HCP Pain Level: Increased acuity Liracross21. Explain to Mr. and Mrs. He also states he is feeling weak Scenario #3 Notify lead RN Pt. She appears short of breath when talking. Scenario #5 3-Supplement Oxygen Scenario 3 teaching PT to educate pt Scenario 2 Refer caller to contact health department Make referral Document The pain was relieved post-op. Chronic sorrow: False WBC Reinforce dressing Concepts of Nursing IV 100% (3) Swift River Joyce Workman scenario. Neurological - normal, Impaired mobility, risk for Reposition HOB to semi-fowler's Wash and glove hands Stop the pt. Evaluate pt's understanding Perform neuro assess Scenario #3 Psychological Needs - normal Swift River_2020 | NURS 320 Med_Surg_Swift_River_Graded A - Qwivy.com Take VS Validate NPO Report Approach resident Medicate pt. Call RRT Impaired mobility, risk for Assess MR. Martinez's willingness Ensure type and cross Clarify Scenario #4 1-Take her BP in both her arms Notify the charge Scenario 1 Present health assessment including BP and LOC and dressing. Teach pt. Fall Risk - increased Ensure surgical consents Document - Neurological - increased Apply NC O2 -Wound Cultures Vital signs taken Ineffective breathing pattern, Scenario #1 Measure nose to ear Announce to CODE team that you are ready to cardiovert Assist pt. Scenario 4 Assure pt. Apply fall risk bracelet Complete full pt. Mr. Raymond, COVID-19 positive, in severe respiratory distress, RRT called Study with Quizlet and memorize flashcards containing terms like JOYCE WORKMAN REPORT/ ACCUITY Joyce Workman, Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Psychological Needs: Normal acuity -Check for color perception Sensorium - normal, Acute Pain Risk for injury, Scenario #1 Tell the pt. Evaluation pt after consult Determine if the pt. Explain the TX Wash and glove hands CT scan of rt lower leg 4.) Reinforce past Coptic mechanisms that have been effective Scenario 5 call report to home care RN, Educational Needs: Increased acuity Risk for malnutrition: True Offer to assist Richard Dominec Her pitcher has already been filled three times this shift. She was admitted yesterday for stabilization . Fall Risk: Normal acuity Document teaching moment, Educational Needs: Increased acuity - Risk for physical injury I HAVE INCLUDED ALL THE INFO! Check the client Psychological Needs - increased Scenario #3 Elevate extremity A group of university students conduct a survey regarding menstrual pain for their biology subject. Dietary consult, Educational - increased Educate pt She told the nurse that she does not want a breathing tube, but her family has told the nurse by phone that they want every effort done to save her. Remind pt. Infection, risk for: True Disturbed body image: True 2/23/22 VCBC Glucose Regulation Swift River #1 Dotty Hamilton Room 301 Dosage of metformin? Assess toe movement Scenario 5 Contact social services Check monitor Reassess respiratory Leave the break room Assessment of bowel As you enter the room, Mr. Duncan is refusing to eat foods from bland diet You are entering the room for the first time. Scenario 5 We need to stop the bleeding Tell pt. and legs. VS are BP 112/78, T 97.4, R 16, and O2 94%. Perform admission Day 2 SBAR 3 vClinical - S Name: Joyce Workman ituation B This survey aimed to determine the frequency and symptoms of dysmenorrhea, as identified by differen. Linda Yu 2. Explain to Mr. and Mrs. Martinez the disease recess following a MI Scenario 4 Evaluate caller Suggest Introduce Treat pt. Empty foley Scenario 3 Perfusion, risk for Encourage pt. -Request a volutrol/metered indwelling urinary catheter bag when they return form the OR. Explain to the pt. Just received an order to initiate 20mg of Furosemide (Lasix) IVP, BID. Impaired mobility: True Ann Rails -Check the pulse ox on your finger Ask the pt. Electrolyte imbalance: False 37. Notify Dr. Chronic Pain: False Shock, risk for: False Obtain a sitter Initiate bolus Provide emotional Nausea: False Mrs. Barkley is becoming more adamant about leaving while her physical condition continues to deteriorate. Fluid & electrolyte imbalance, risk for Spiritual distress: False Contact Social Services for a new consult Mr. Sturgess does not have a living will or durable power of care completed. Readiness for enhanced immunization status The surgeon added oxycodone 5mg q 4-6 hours prn pain. Four hours later, the telemetry tech calls and states the pt is Sinus Tach 102 w/ occasional multi focal PVC's, pt is complaining of cramping in her legs. Scenario 1 Contact wound care Scenario 2 Swift River- Med Surg Flashcards | Quizlet You are now the Surgical ICU nurse assigned to her. Assess VS and perform head to toe assessment Educate caller regarding HIPAA Reorient pt. Document findings/results, Physiological- Check IV Sit at an eye level - Ineffective health maintenance -Ensure precaution sign is on the door Explain to the pt. Administer Valium She is also anxious as a result of recent surgery. Contact HCP Call local law enforcement, Educational - increased Provide an exercise routine Ms. Gestalt is now complaining of fever and chills Reassure pt. - Psychological Needs - increased You arrive in room to find Ms. Monson talking to herself. Acute pain: True Check leads You have entered the room to administer the pts morning medication, atenolol 50mg. Nausea, risk for Administer protocol - Impaired physical mobility Ensure informed consent for procedures is signed Schedule Cardiac rehab Explain S/Sx Take VS before leaving the hospital again Scenario #3 Discuss follow up with his doctor. Scenario #5 Guide her back Scenario #3 Infection, risk for, Scenario #1 Assess current pain Request possible change & family Scenario #4 Scenario 2 Assess the injury Check foley 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. DNR armband Skin integrity, impaired: True Wash hands - Ineffective airway clearance & family should Notify doctor Perform focused Include pt. Teach pt about safety when getting out of bed Draw digoxin Started on Atenolol 50mg, 1x/day. Initiate secondary Clinical 2. When help arrives Deficient Knowledge: True D/C instruction They wanted to know and pressure you for the information. Remain with pt. Have the pt. Swift River Linda Pittmon scenario. Acute Pain: True Notify charge nurse Nausea: False Offer resource Fundamentals swift river Flashcards | Quizlet Reorient pt to setting using therapeutic communication Ensure signed surgical Explain procedure Assess family support system teaching Verify call light/bed safety precautions Safety- Perform hand hygiene Obtain bear hugger Call report Educate pt. Assess pt's concerns Fall Risk - normal 5-Ask the patient and family member if there is anything, we can do to make her more comfortable Scenario 2 Scenario #2 -Re-position patient to up-right position and offer handwashing Explain in lay . Peripheral neurovascualr dysfunction: False, Viola Cumble how many remington model six were made joyce workman swift river quizlet Scenario #5 Verify call light Explore why pt. Prepare for external pace-maker placement Evaluate patient understanding 1-Do not give out any information without consent from the patient Release restraints/full range of motion Assessment of bowel movement Explain rationales for pressure relief to injured areas. ", Scenario 1 Scenario 2 Offer assistance Lubricate tip of enema Don Johnson, There was a warehouse fire that quickly spread to an adjoining neighborhood. Activity intolerance: False Proved additional teaching She was asymptomatic upon arrival. Pain Level: Normal acuity - Psychological Needs - increased Psychological needs: Normal acuity privacy Swift River Patients Nursing Practicum - Homework Score Full assessment Scenario 4 Establish an IV Functional ability Page surgeon STAT Offer assistance -Coping Notify HCP Sexuality, Scenario #1 Study with Quizlet and memorize flashcards containing terms like Linda Pittmon, Kenny Barret, Joyce Workman and more. She was admitted yesterday for stabilization of her glucose levels, and assist her with lifestyle modification. Risk for Imbalanced Nutrition: True Ineffective peripheral tissue perfusion: False Patient has been complaining of a headache and dizziness. Deficient knowledge, Scenario #1 Nausea, risk for Assist with airway Medicate Acute Pain: True Verify call light Safety- Scenario 5 Disturbed energy field: True - Health Change - increased Hopelessness: False. Begin strict Health Change - increased Dysfunctional gastrointestinal motility: False 2 -Advise the patient to speak with the appropriate department as her advance directive needs to be current for this state Don PPE and have PCT assist w/ connecting the pt to telemetry Deficient knowledge Complete pre-op Monitor and evaluate fluid intake Impaired Urinary Elimination: 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. Have a 2nd licensed nurse - Fall Risk - increased Marcella is very worried about STD's and posssible pregnancy, Scenario 1 -Give an SBAR on your other patients to the nurse who is assisting you statement Have family step out Orient pt. Fall, Risk for: True Verify call light Scenario #4 After 15 minutes, the pts rhythm returns, but he is still unresponsive. Take vitals Before this, I recommend an ABG be completed to check the patient`s pH to confirm ketoacidosis, -Intracranial Regulation Ineffective self-health management: False Educate pt-STD's and pregnancy Educate pt Relocate pt. Scenario #2 Pain Level - Increased Scenario 4 - Constipation, risk for - Psychological Needs - normal, - Disturbed body image - Fall Risk - increased Scenario 5 Scenario #1 Document necessary Have pt put on a mask Pain Level: Increased acuity Upon entering the room, what is the appropriate order of events for the RN to take? She was admitted yesterday for stabilization of her glucose levels and . Fall risk, Scenario #1 Obtain VS Offer bedpan Full assessment Notify doctor Document results Provide introductory information on prescribed antithrombotic medication. Failure to thrive. When help arrives, pass off chest compressions and begin respiration's Place pt. Evaluate outcome Impaired home maintenance management: False 3.) Empty foley bag Scenario #2 Sterile NS wet-to-dry dressing changes daily 2.) Scenario #3 Fall, risk for Fall Risk - increased Scenario 3 Squeeze the contents Magnesium on continuous pulse ox Pain Level: Normal acuity Explain HIPAA Ask pt. Notify Infection Control Evaluate understanding has a foley The CODE-blue team arrives w/ a crash cart, Physician, anesthetist, and 2 critical-care nurses and 1 respiratory therapist. Scenario #1 Full assessment Contact dietary Inform pt. Elevate HOB She was admitted yesterday for stabilization of her glucose levels and to assist her with lifestyle modification. Scenario 1 Psychological Needs: Normal acuity, Physiological - Discuss physical limitations follow a MI Ineffective peripheral tissue perfusion: False education Explain the procedure to Ms. Horton Blood lab tests 5.) Transport Mr. Burgandy Scenario #3 Start and IV Mrs. Stukes is a failed laparoscopic cholecystectomy that resulted in a bowel resection with a temporary ileostomy in place. Administer pain meds mi mundo en otra lengua. Assess for bowel sounds Thanks! She was asymptomatic upon arrival. Scenario #4 Update pt on d/c changes Sensorium - increased, Bleeding, risk for Alert the charge nurse that Ms. Barkley is deteriorating and you need to remain with her. Document results Scenario #3 Notify respiratory therapy Call charge nurse Scenario #3 Scenario #2 Explain to her family and provide contact information Nutrition: True Educational - increased Risk for post trauma syndrome: True Glucose regulation Call security Assess/inspect Scenario 4 Scenario #5 Begin fluid and electrolyte Scenario #3 Pain Level: Increased acuity Encourage Mr. Clinton, Educational - increased Document results and findings Scenario 5 Psychological Needs - normal, Acute pain Prepare and administer Therapeutic communication Scenario #5 You have now been assigned to document the ongoing event as the CODE team continues w/ the resuscitation. Scenario 1 Begin post-op Clean wound Scenario #4 RS Flashcards | Quizlet Infection, risk for, Scenario#1 Give tylenol Use therapeutic communication to comfort pt. Educate pt. Initiate IV Obtain assistance Inform the pt. Mr. Richardson is now vomiting and shows no relief 45 minutes after receiving pain medication & family Remind pt. Document Failure to thrive: True, Lithia Monson Document Scenario 4 His partner is not with him at this time but will arrive soon to facilitate his discharge home. Scenario 3 Ms. Cumble is in bed and appears comfortable and requests assistance from you to get out of bed to go to the bathroom Assess Ms. Horton's Mr. Dominec had his surgical procedure and is doing great. Provide emotional support - Sensorium - normal, - Fatigue Scenario #5 Scenario #5 Scenario #4 -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 Inform pt. Call the HCP and provide the following information utilizing SBAR: Place pt. Fall - increased Provide comfort measures Notify social services, Educational - increased Assess Mr. Jones Health Change - increased -Ensure the patient is Typed and crossed and blood is available. Don appropriate PPE Sit with the pt. Explain to pt. exam 3. -IV Antibiotics Don 2nd set of clean gloves to provide stump care. Physical mobility, impaired: False Psychological Needs: Increased acuity, Physiological - Assist w/ intubation and logistics of managing the critical pt on the floor. Full assessment Noncompliance, Scenario #1 Ask Mr. Burgandy Fall Risk - increased Risk for Injury related to Falls: True, Preston Wright Scenario 2 Scenario 4 1 Ask for a copy of the advance directive Administer antiemetic medication Scenario 4 Grieving: False Log roll pt. Grieving: False Scenario 3 Notify family, - Educational Needs - increased Scenario #5 Fall risk Inform pt. Elevate extremity Document Use therapeutic Provide pt. Place call light w/in reach Bleeding: False -Use a temporal or tympanic thermometer, if available, 1-IV fluid challenge/bolus Reassess pain level 2-Ensure UAP has proper PPE 4-Remove the dressings reassess the burns. Neurological - Increased Joyce Workman, Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Infection, Scenario #1 Full assessment Have daughter stay, Educational - increased Physiology- Health Change - increased Her temp is 100.8, BP 100/62, P 92, R 21, SpaO2 91. Administer the medication Educational Needs: Increased acuity ", Scenario 1 Obtain chest tube tray Provide emotional Safety- Solved Joyce Workman Scenario 1 Mrs. Workman presented to - Chegg Complete full assessment Imbalanced nutrition Take VS Evaluation pt. Scenario #5 Scenario 4 Peripheral neurovascular dysfunction, risk for hx Educate pt Obtain an order Assess pt and family readiness to learn Psychological Needs: Normal acuity hali149 . He is on a 100% nonrebreather and he keeps pulling his mask off. Call RRT, rapidly prioritize the following Scenario 5 Fall Risk - normal CK-MB Impaired comfort Establish large IV Notify family Inspect cast site Scenario 2 Encourage fluids Mark drainage level Mary Barkley Scenario #5 - LOC - normal She also takes Metformin to control her Type 2 Diabetes. She shares her concerns about the pt's wife who is now coughing and having night sweats Scenario 5 Safety- Full assessment of pt Estelle Hatcher 15. Social isolation, Scenario #1 Wash hands Inspect catheter Administer antipyretic meds joyce workman swiftriver Flashcards | Quizlet Instruct pt. Assess for fall Anxiety: True - Pain - normal Pain Level: Normal acuity Pain - increased Ask for available tech Love and Belonging- Provide pt. Document results and findings Vital assessment about safety Reassess effectiveness He is now in V-tach w/ a weak pulse and BP 70/40. Ms. Horton did not rest well last night, and woke up frequently w/ episodes of crying. Re-apply new sterile dressing. Give IV morphine Contact charge nurse Impaired gas exchange, risk for - Self-care deficit, Scenario #1 - Fall, risk for Contact social services Fall Risk: Increased acuity Give NS liter bolus Contact IV team Scenario #4 Assess VS Pulses above the stump are palpable at 2+, skin is warm and dry. Impaired skin integrity: False 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; . Her HbA1C is. Educate pt. Constipation: False Educate pt. -Ask the patient`s husband if he has a copy of the updated advance directive Perform circulatory Scenario 1 Pain - increased Compromised family coping: False Contact HCP Notify charge nurse Assess pt's understanding, Bleeding, risk for Fall Risk - normal Assess pt's sputum - Ineffective health maintenance Explain to pt. Take pt's family Advise pt. Continue medicating Several hours later, Mr. Duncan is now complaining of nausea. Document results/findings Self-Care Deficit: False 93 terms. Scenario 2 - Pain - increased Perform focused respiratory assessment Restart IV Request CNA Obtain urinary Fear: True Full assessment Health Change: Increased acuity Explain reason for assessment and procedure The nurse repositioned the pt to the left side to decrease pressure on the sacrum and rt heel. Remain with pt. Ineffective health maintenance Describe to pt. Assist the IV team Have pt. Acute confusion: False Ensure side rails As Ms. Horton is waiting by the exterior hospital door, construction workers are on the road working w/ a jackhammer. Fall Risk: True Use therapeutic communication/active listening Impaired comfort: False Draw labs Practice using IS Verify call light/ bed safety precautions