Risk for injury: True, Scenario 1 Assess for bowel sounds Complete chest x-ray hx Enter the room after taking VS. Mr. Martinez will now start taking long term antithrombotic therapy. Pain Level: Normal acuity 2-Ensure UAP has proper PPE Repeat 1mg atropine Educate pt She is oriented x3 but at times seems to be talking to someone in the room when no one is present. Call for CODE-blue Infection, risk for: False q 5 min Escort pt. Assessment of bowel (b) If the osmotic pressure of blood at 25C25{ }^{\circ} \mathrm{C}25C is 7.707.707.70 atm, what is the direction of solvent movement across the semipermeable membrane in dialysis? Scenario #3 4-Offer to assist in completing an advance directive Assess the pt Sensorium: Normal acuity, Physiological - Asses Mr. Wright's willingness 4-I suggest that you start the patient on an insulin glucose infusion with a blood glucose check q hourly. Impaired gas exchange: True Disturbed body, Scenario #1 Encourage fluids Healthcare provider has ordered Haldol in order to sedate the pt. Kenny Barrett Full assessment Scenario 4 Psychological Needs: Increased acuity, Educational Needs: Increased acuity Fall, risk for, Scenario #1 Infection risk: True Scenario 5 Pain - increased Disturbed body: False Leave the break room and not continue in conversation. Advise pt. Sarah Getts Assis pt. Notify lead RN/ DR of new circumstances He has been informed that for the next 18 months he should take antithrombotic therapy daily. Scenario #5 Notify the physican of assessment findings and await further orders Ms. Cumble is in bed and appears comfortable and requests assistance from you to get out of bed to go to the bathroom Continue medicating call light -Reapply Silvadene and sterile dressings. Make referral Offer assistance Scenario #2 Scenario #3 has a foley Explain to Roger Offer to contact family for HCP. Acute confusion Evaluate pt's understanding Hold next dose of Atenolol if BP <130/80 Impaired gas exchange: True Review medication Vital signs are BP: 146/94, P: 88, R: 22, T: 99.2, PaO2: 94% Blood glucose upon admission is 340 mg/dl. Provide SBAR Infection, risk for, Scenario #1 Initiate a second 18g IV Neurological - normal Alteration of protective mechanisms: True. Fall, risk for Acute Pain: True Begin list of medications and time/dose given. Impaired comfort Scenario #4 Sleep Deprivation False Don 2nd set of clean gloves to provide stump care. Administer pain meds Document Begin post op education for day one Scenario 1 Scenario 2 Tell the mother that visitors are welcome Deficient knowledge: True Wash hands Use therapeutic Document, Educational - increased on 100% O2 Safety- Mark drainage level Wash and glove hands Don clean gloves Scenario 2 Scenario 3 statement Place steps in order. Impaired mobility: False -Inform Mr. Goodman that his girlfriend called about his status. Sensorium: Normal acuity, Educational Needs: Increased acuity Contact assisted living Health Change: Increased acuity VS are deteriorating, BP 90/58, P 116, R 28, PaO2 85%, T 102.0. Administer the medication Report finding to HCP using SBAR. Inform pt. Scenario 3 5-Inform the team that the patient has an advance directive to include no intubation and no CPR Scenario #3 You discuss this cough Assessment of bowel movement Virtual Clinical- Swift River Week 4. Notify lead nurse Wash and glove hands Scenario 2 The next day, he tests positive for COVID-19 and his condition has deteriorated as he is now in respiratory distress. 2-Stop the infusion Disturbed body image: False Scenario #2 Educate pt. Ensure pt. Verify call light Family at beside. Verify soft, low sodium Initiate IV Heparin Set up sterile Psychological Needs - increased 3-Contact the provider and document the patient respiratory status. Safety- Educate pt Scenario #4 Deficient knowledge Apply new dressing Notify family Evaluate pt. Discuss willingness Initiate IV Summarize Sensorium - increased, - Electrolyte imbalance -Ask the patient`s husband if he has a copy of the updated advance directive Give pt. Constipation: False Complete assessment Maintain strict I&O's Elevate stump, - Educational - increased Family dynamics Ensure documentation The patient`s mental status is, stable; she is awake, alert, and oriented. Skin integrity at risk Health Change - increased Psychological Needs: Normal acuity, Physiological- She has been documented as being obese, new-onset hypertension, polyuria, and a rash on her abdomen. Document results Place sterile moistened Educate pt. Scenario #2 Risk for Injury related to Falls: True, Preston Wright Should I be concerned about having sex w/ him? The indicator HIn has an acid dissociation constant of 4.80 \times 10^ {-6} 4.80106 at ordinary temperatures. Ask pt. Ask the charge nurses to assign another nurse to the new admission. Vital assessment -Test patient's vision with number of fingers, objects, etc. Spiritual distress: False Call report Place pt. Scenario 5 Full assessment Self-actualization- Dr. Sangerstien. Have pt. Prepare the patient for possible intubation Scenario 5 This information Assess pain Attempt to orient Wash and glove hands Obtain Spanish Document results She receives the pre-op medication. Call Report, Educational - increased Drug therapy: True Hydrocodone 5 mg Acetaminophen 325 mg (Norco 5mg) 1-2 tablets every 3-4 hrs PRN moderated to severe pain #30. Electrolyte imbalance: False acquire daily weight and food intake Monitor for adverse Swift River Joyce Workman scenario. Patient has been complaining of a headache and dizziness. Health Change - increased Scenario #5 Scenario #2 Change IV fluids to 75ml/hr 8.) Scenario #3 WBC Seek clarification 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. Put an arm band Scenario #3 Provide emesis basin Give ASA Glucose regulation Reinforce need Day 2 admission, Thomas Richardson is complaining of severe pain and is now begging you for some relief; states pain scale 10/10 Scenario #2 Use therapeutic communication/active listening Take initial VS Request the uncle come Inform pt. Scenario 4 Teach pt about safety when getting out of bed Alert Mr. Wright's case manager of concerns of home environment. -Review of body systems and evaluate pain on a scale of 1-10 Scenario #5 Notify MD for F/C Clarify w/ Mrs. Martinez that she is asking if it is okay to resume sexual relations w/ her husband upon d/c. Notify MD of worsening changes to wound based on measurements and appearance 4.) Clinical 2. Begin post-op Discuss lifestyle choices Place personal aspirin Hypothermia: False Acute Pain: True Notify cath lab for stat cardiac cath The RN calls the attending provider requesting that Ms. Barkley be txf to ICU but there are no rooms available. Ensure continuous EKG monitoring Fall Risk - normal Risk for infection, Scenario #1 He also states he is feeling weak Reorient pt. Interviewing pt. Explore new ways Explain to surgeon Fall Risk: Increased acuity Assure the pt. Bleeding, risk for: False Reassure the pt. Scenario #5 Neurological: Normal acuity She has arrived at 0600 and is scheduled for a laparoscopic Roux-en-Y gastric bypass (RYGB). Head-to-toe Scenario 2 Scenario 1 4 Psychological abuse Impaired mobility, risk for Scenario #4 Assess pt. Health Change - increased Pale pt. & family Accompany pt to ICU and give report to receiving RN, Educational Needs: Increased acuity Health Change - increased Do not probe Assist with airway Could he have another heart attack? Ms. Horton hears the jackhammer and then screams and dives to the floor. She is experiencing polyphagia and polydipsia with blurred vision Evaluate pt's understanding Apply Silvadene Scenario 3 She is very excited about the surgery but is also apprehensive. Provide education regarding HF - Imbalanced fluid volume, risk for Provide morphine John Duncan Room 302 Joyce Workman Room 303 Meds for new dx diabetes? Request order jasmine_347. CPK Notify Dr. Fall Risk: Increased acuity Scenario 3 Have IV abx amiable to administer when surgery calls for the pt to be transferred to pre op area. joyce workman swift river quizlet. Promote open Scenario 2 Bleeding, risk for 1. Alert ICU Use therapeutic Provide comfort Anxiety False Neurological - normal She has just been transported from recovery. Mrs. Smith shares w/ you that even though she signed the operative consent she was not sure if this was the right surgical procedure for her. Health Change: Increased acuity Contact RT Assess airway Document results 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 Inform the pt. Assess pt's sputum Mr. Richardson is requesting assistance to ambulated to bathroom Health Change - increased Record I/O PT to educate Shae_Quinn9. Document Educate pt. Rank as most concerning for labs Scenario #5 Scenario 5 Explain reason for assessment and procedure Witness signing Reinforce provider teaching Psychological Needs - increased Scenario 4 Empty foley Infection, risk for. Ineffective peripheral tissue perfusion: False Scenario 4 Maintain strice Mr. Raymond is stabilized w/ RRT. Place sterile moistened sterile gauze in wound, place ABD pad over wound. privacy Use therapeutic communication/active listening Scenario 3 Ensure surgical consents -Mobility Ensure there is suction Three hours later, Ms. Getts is unsteady when standing by her bedside. Assess for therapeutic response to medications Mr. Dominec had his surgical procedure and is doing great. Document results and findings Contact wound care Obtain translator Scenario 1 Discuss coping Notify charge nurse Scenario 5 Document Conversation, Educational Needs: Increased acuity Provide report to ER RN, Educational Needs: Increased acuity Assist with insertion Neurological - normal, Scenario #1 Scenario 2 Perform pain Assess vital Reassess pain Educate Mrs. Workman Assess VS & UO All 5 toes on the right foot are necrotic, absent pedal pulses, skin cold to touch, appearance dry, cracked and black up to mid-calf. Acute Pain: True -Ensure precaution sign is on the door Provide information to Mr. and Mrs. Martinez regarding support groups, Educational Needs: Increased acuity After your AM assessment, the pt's call light goes on and she is complaining of nause, abd pain, and seeing "yellow circles". Please fill in any remaining missing answers, and let me know if anything is incorrect. Noncompliance: True Reassure pt. You have now been assigned to document the ongoing event as the CODE team continues w/ the resuscitation. Scenario #5 Nausea: False Scenario #5 Inspect site Explain HIPAA - Neurological - increased You enter room and find Ms. Gestalt crying because she has just learned her medical insurance has lapsed and she is already two months behind on her car payments. Swift River- Community Health. -Grief Prepare for external pace-maker placement Notify RRT Explain to the wife Notify family to self-isolate for 14 days Vital assessment Scenario 1 Make sure accurate wt. Administer digoxin -Perfusion Ms. Cumble states that she has not had a BM for three days Check surgical consent Notify lead nurse Contact charge nurse Fall Risk - increased Scenario 1 Summarize discussion Ramona Stukes Anxiety: False Mr. Wright is pleasant and cooperative but needs to be reminded to avoid pressure on his heel and sacrum. Discuss w/ pt. Take VS & provide pt. The nurse has Ms. Horton in the wheelchair ready to be taken down to the lobby by the UAP. Evaluate pt understanding Health Change: Increased acuity Love and Belonging- Clarify Check foley Concepts of Nursing IV 100% (2) Deanna Concept Map Assignment 1. immediately. Explain the necessary procedure She is requesting the names and home phone number for the wound care nurse who saw Mrs. Stukes while she was an inpatient. Just received an order to initiate 20mg of Furosemide (Lasix) IVP, BID. Deficient Knowledge: True Notify HCP Encourage Mr. Wright to include high protein snacks in his diet ETOH withdrawal, risk for, Scenario #1 Gently peel off Impaired Skin Integrity, Risk for: False Document results and findings Explain to Mrs. Whitmore Pain Level: Increased acuity Change dressing Pt Kenny Barrett is nauseated and complains of dizziness when he sits up. Preston Wright, 73-year-old male patient of Dr. Greene, status post CVA 4 weeks ago. Donald Lyles, 52-year old male, was admitted yesterday evening for stabilization of his uncontrolled type II diabetes. year-old female who presents to the Diabetes Clinic with a new. Document and accompany pt to ICU immediately, and handoff report to receiving ICU nurse, Educational Needs: Increased acuity Scenario #3 Request additional pain med Contact CC's uncle -Check pulse Ox, -Cognition Body image disturbance: False Wash hands Document physical findings Assess VS Full assessment Sarah Kathryn Horton 13. Ensure cardio-pads are in place anterior chest and posterior back Take vitals She is to notify the nurse upon return to the clinic from the lab. Acute Pain: True Safety - Psychological Needs: Normal acuity, Physiological - If cardiac Sensorium - increased, Scenario #1 -Notify HCP and nursing supervisor -Explain to Mrs. Barkley that you are going to change her linens Sensorium: Normal acuity, Physiological- Remove the lunch tray Construct dietary consult (plan) Initial assessment Pt. ShannonLamb1. Notify lead RN/Dr. Scenario 2 He replies," six times in the past four hours". Draw stat D-Dimer Full assessment Neurological: Normal acuity Call the HCP and provide the following information utilizing SBAR: Educate pt. Encourage the HCP to consider intubation in the absence of signed DNR. He states, "thiss is not serious." Notify HCP Document results and findings Orient Roger Scenario 4 Contact social services Explain to Mr. Greer Deficient knowledge Fall Risk - increased Initiate head-to-toe Ensure the bed Request repeat jessdevan. 5-Use therapeutic communication to convey empathy Bleeding Bleeding: False Mr. Duncan is now complaining of feeling "dizzy" when he stands Deficient knowledge Therapeutic communication Notify charge nurse Vital assessment and legs. Reinforce past Thermoregulation Scenario #2 Assess for therapeutic Inform pt. Call HCP He refuses to comply with dietary recommendations. Obtain a sitter/UAP Intubated by RRT, BP 88/58, P 110, T 101.2, SaO2 94%, ABG's are pending, F/C in place. Approach resident Imbalanced nutrition - Impaired comfort Retake VS (BP 110/70, P 94) Adjust crutches Sulfamethoxazole 800 mg, Trimethoprim 160 mg (Bactria DS) 1 tablet PO daily 5.) Psychological Needs - normal, Scenario #1 Scenario #2 Course Hero is not sponsored or endorsed by any college or university. Ask charge nurse, Educational - increased Place pt. Scenario 1 -Check her blood glucose She is 2 days post-op. teaching -Administer pain medication and call provider for a fentanyl or hydromorphone hydrochloride prescription. Fall Risk - increased Give your answer as a percent and round to one decimal place when necessary: 27.4%81\frac{27.4 \%}{8 \cdot 1}8127.4%, (a) Calculate the osmotic pressure of the hemodialysis solution at 25C25^{\circ} \mathrm{C}25C. Ensure pt. -Determine if drainage is increasing Use therapeutic Scenario 3 Ensure type and cross match for blood products is complete and results are in electronic medical record Scenario 2 Obtain burn sheets Present health assessment including BP and LOC and dressing. Psychological Needs: Normal acuity Check blood glucose Neurological - normal, Chronic pain - Fall, risk for -Safety Fall, risk for: True Verify call light Provide therapeutic Safety: Increased acuity, Physiological - mi mundo en otra lengua. NG tube to LIS Relocate pt. -Consider warming the patient's hands to get an accurate reading - Fear Deficient knowledge Inform his partner -Explain HIPAA policy to the girlfriend Administer levofloxacin to apply Document Administer antipyretic meds Inform admitting physician Notify Dr. of change Pt. Have an aide sit w/ Ms. Barkley while you obtain the IV supplies and notify the HCP of her declining condition. Educational Needs: Increased acuity Check pedal capillary refill Give an SBAR to hospitalist, Scenario 1 Her HbA1C is. Joyce Workman, a 42-year-old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. 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. Obtain urinary Ask PCT Social isolation, Risk for: True, Educational Needs: Increased acuity Make sure O2 mask Scenario #3 Educated pt/family Physical mobility, impaired: True Wash handa Educate caller - Pain - increased Scenario #3 Take VS Vital sign assessment Swift R clinicals. Assist pt. Assess whether or not Announce, "CLEAR Call for triple lumen Document Acute pain: True Peripheral neurovascular dysfunction, risk for -Apply new probe cover to probe before assessing temperature Sensorium: Normal acuity, Physiological- What was the priority nursing assessment (s)?-Russel Montgomery- Spinal Injury: assess neuro, musculoskeletal, respiratory-Thomas Bechman- Gout &amp; Dementia: assess integumentary, neuro, musculoskeletal, endocrine (for levothyroxine) -Louis Hutchinson- Amyotrophic lateral sclerosis (ALS): musculoskeletal, neurological, integumentary Scenario 4 Scenario #3 3.) Evaluate understanding Ask parents Scenario 5 Scenario #2 5-Take an axillary temperature with the blue electronic thermometer Psychological Needs - increased Complete full assessment Wash/glove Remove infiltrated IV swallow Attempt to restart IV Tom Richardson Body image, Disturbed: False Contact HCP Educate pt. Ms. Como is first day after sexual assault. Administer IV ABX Pain - normal Complete neuro Place pt. Psychological Needs - normal Swift River Joyce Workman Room 304. Deficient knowledge: False Impaired mobility: True Health Change - increased Impaired Skin Integrity, Risk for False Monitor and evaluate fluid intake Assess respiratory - Impaired mobility -Inform the patient that he will have plenty of time to decide, and the Provider will discuss all the options with you Check physician orders Scenario 4 Call for crash cart Evaluate understanding Social isolation: True, Marcella Como Provide emesis basin/cloth Ask the pt. Restart the IV - Deficient knowledge Provide initial report and assist RRT Provide comfort & family Give iv morphine 2 mg IVP Scenario 4 Scenario 3 I HAVE INCLUDED ALL THE INFO! Scenario 2 Dressing change q 24 hours to RT thighs and rt shoulder. verbalize, Educational - increased Don clean gloves and removed the old dressing. Health Change: Increased acuity Scenario 2 Ensure documentation of time and events of RRT Contact head RN Nausea Assess pt's ABCs - Impaired tissue perfusion Ms. Getts is being transferred as an emergency to Critical Care. Scenario 1 Contact funeral home Asses pt. Impaired home maintenance management: False

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