Take VS Scenario 4 You are entering the room for the first time. Perform neuro Scenario #2 - Health Change - increased Vitals? - Anxiety Ensure IV access Scenario 4 Neurological: Normal acuity Scenario #3 1-Introduce and sit down by the patient's bedside Hand hygiene Continue to encourage Educate pt. Scenario #2 Assess -Request a volutrol/metered indwelling urinary catheter bag when they return form the OR. Clinical 2. Risk for injury, Scenario #1 Reassess BP & P Health Change: Increased acuity Risk for imbalanced nutrition Full assessment Evaluate pt. Talk with Mr. Jones Mr. Sturgess is uncomfortable w/ experiencing urinary frequency that keeps him from resting Fear: False - LOC - normal Fall, for Risk: False 2-Have the patient rest in the same position and repeat BP assessment in 15 minutes Current VS BP 110/70, P 94, pt is pale, dizzy and nauseated. Imbalanced Fluid Volume, Risk for True Scenario #3 Safety- Ensure the bed Perform initial assessment Adjust rate of IV Report Mr. Martinez's Explain the TX Education Infection, fisk for, Scenario #1 -Inform Mr. Goodman that his girlfriend called about his status. Scenario #4 Provide comfort in pre-surgical room Mr. Dominec. Wash hands Assess if the contents Inspect pleurovac Ms. Gestalt capillary refilling is now 6 seconds below cast site, extremity is swollen and cold to the touch Remove clean gloves, wash hands, put on sterile gloves if it is okay Scenario 2 Scenario 4 Fall Risk - increased - Self-care deficit, Scenario #1 Impaired mobility, risk for You are now preparing for d/c. you take his vital signs which are T 101.3, P 88, R 24, BP 116/84 Reassess VS Scenario #4 Acute pain: True Provide Mrs. Workman Esteem- Scenario 3 Evaluate understanding Start and IV Orient friend Alert? Explain the need Neurological - normal She was asymptomatic upon arrival. Check proper Disconnect NG tube 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. Perform The surgeon added oxycodone 5mg q 4-6 hours prn pain. Perform pre op checklist Announce to CODE team that you are ready to cardiovert Verify call light Assess respiratory Document Deficient Fluid Volume, Risk for: True Seek clarification 1-Take her BP in both her arms Scenario #5 Psychological Needs: Normal acuity Mr. Dominec had his surgical procedure and is doing great. Notify HCP Anxiety Ms. Gestalt is now complaining of fever and chills Offer masks to visitors Notify lead RN/Dr She is frustrated and overwhelmed with the new appliance not working properly. Scenario 4 Infection, risk for, Scenario #1 Auscultate -Ensure there is no fingernail polish on the pulse ox -Remind students of HIPAA policy, and report observations to the Nursing professor Set her up w/ a video chat w/ her family He also states he is feeling weak Teach pt. understanding Discuss support groups, Educational Needs: Increased acuity Evaluate understanding Inspect pain Health Change - Increased Remove the dinner tray Recheck Tilts Scenario 2 Document physical findings 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. Assist RT Full assessment Hold next dose of Atenolol if BP <130/80 Health Change - increased Check patency CT scan of rt lower leg 4.) Offer full AM bath Scenario 4 Have IV ABX Mr. Jones stated to the nurse that he "was scared to leave the room." Further questioning and clarification revealed Mr. Jones does not want to be alone and is afraid of being hurt . Impaired comfort Fall, risk for Impaired gas exchange: True Post-op assessment Scenario 4 Empty foley bag She is 2 days post-op. Check VS Carlos Mancia 11. Therapeutic communication Document Start PCA pump Decisional conflict: False teaching Educational - increased Estelle Hatcher Ensure signed surgical Pt. Psychological Needs: Normal acuity, Physiological - Place personal aspirin Apply NC O2 Deanna Concept Map Assignment 1. Evaluate pt. Monitor neurovascular Encourage Mr. Wright Wash and glove Pain Level: Normal acuity Encourage PO fluids 9.) Pain - increased Sensorium - increased, - Electrolyte imbalance see the plan of care: 1.) Inform the pt. Have nursing personnel in the room when family visit, Gas exchange Concepts of Nursing IV 100% (3) Swift River Joyce Workman scenario. Powerlessness: True Administer protocol antidirrheal medication It is now 2 wks later; Mrs. Smith has returned. Legal in Canada since June 2016 Implications? Administer Noncompliance: True, John Duncan understanding, Acute pain Assess Mrs. Workman's understanding Wash & glove Secure dressing place with tape Scenario #5 Scenario #2 Anxiety: True Teach pt. 1-I am calling about Joyce Workman. Notify doctor Wash and glove hands He is still unresponsive. What were the voices telling you? Educate pt. Notify charge nurse of protocols Bleeding: False -Make sure the room temp is 84.0 F/29.0 C -Give an SBAR on your other patients to the nurse who is assisting you The problem I am calling about is, her blood glucose is high. -Reapply Silvadene and sterile dressings. - Fall ,risk for Discuss willingness Levofloxacin (Levaquin) 750 mg IV q 24hrs You are about to call the Surgical ICU and give report. Fall, risk for: True What order are you providing the information to the receiving nurse? Place pt. Observe closely first hour Place pt. Administer IV ABX He has been readmitted for a red spot on his sacrum of 1 cm and a 2 cm blister on his right heel. Document Ms. Rails states that she has not had a bowel movement (BM) in the past two days. Acute Pain: True Use therapeutic communication to explain necessary procedure. Ensure cardio-pads are in place anterior chest and posterior back Sensorium - normal, Enhanced readiness for learning Notify MD for F/C Pt is scheduled for and ECG and MRI this AM. Contact CC's uncle Scenario #4 Electrolyte Imbalance: False Record I/O Troponin 1.0 mg/mL Describe the situation and what you did to deal with the situation. Notify lead RN/Dr Scenario 4 Therapeutic communication Check pedal capillary refill Use therapeutic Scenario 1 Communicate w/ the pt therapeutically -Assure patient that she is safe in the hospital, and you will not leave her Scenario 1 Please fill in any remaining missing answers, and let me know if anything is incorrect. Call for crash cart Educate pt. Perform admission Check time Ask Mrs. Workman Escort pt. She was then sent to the lab for ordered lab tests. Noncompliance, Scenario #1 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. Neurological - normal, Scenario #1 Insert F/C Verify if discharge, Impaired comfort Educate pt. Scenario #4 Pain, Acute: True Ensure pt. Continue to provide Stress importance Scenario #4 Obtain VS Assess pain and rhythm Q15 minutes Request possible change Increase supplemental O2 Set-up Scenario 2 joyce workman swift river quizlet 29 Jun. She is super morbidly obese with a BMI of 52, Ht, 5'3", Wt, 293lbs. Notify the social worker, Acute pain Her husband who is present stats, "I thought it was just a lumpectomy she was having this morning." 4-Stop the conversation immediately Assess vital results Document and provide Complete incident report, Acute pain Ask for available tech -Prepare SBAR for arriving team His HbgA1c is 10.6%. Have daughter stay, Educational - increased Reassess lung sounds Scenario #4 Pain - increased Consult with MD Provide operative summary Asses pt. Provide emesis basin Altered body image Contact dietary consult If pt. Assess VS Encourage aggressive IS Document A group of university students conduct a survey regarding menstrual pain for their biology subject. IV with NS @ 125 mL/ hr. -Determine cognition by asking questions to determine if she knows who, where, and what happened Risk for Imbalanced Nutrition: True Scenario 2 Obtain chest tube tray Assist & support Scenario 4 Assist the pt back to bed Scenario #2 Restart the IV Infection, risk for, Scenario #1 Hypothermia: False Bleeding, Risk for: True Assess pt's need Impaired tissue integrity: True Document teaching Evaluate pt's understanding Impaired Mobility, Risk for: True - Skin integrity, impaired Contact HCP Provide pt post MI education Insert new IV Schedule Cardiac rehab Document all findings Scenario 1 Pt is complaining of pain in her shoulder and thigh 7/10 Orient pt. Scenario 4 Scenario 3 Ask the pt if she has had the procedures previously Discuss lifestyle choices Past medical history includes hyperlipidemia, current elevated triglycerides, and a history of 1 pack a day smoker for the past 20 years. Educate family regarding intervention You shouldn't, "Are you okay? Pain Level: Increased acuity Fall Risk: Increased acuity - Deficient knowledge - Physical mobility, impaired on telemetry Risk for infection: True, Donald Lyles Scenario 3 Call for code Explain to Mr. Wiggins Document Instruct pt. Complete neuro Inform Mr. Burgandy Neurological - increased Encourage fluids Tell the pt. Check for breathing and carotid pulse Ask pt. that Wash hands Upon entering the room, you find Mr. Sturgess is quiet, appears tense and rigid but states, "I am feeling fine." Auscultate lungs Document results Ensure there is a full Ms. Cumble is in bed and appears comfortable and requests assistance from you to get out of bed to go to the bathroom Check blood glucose Mr. Wright is pleasant and cooperative but needs to be reminded to avoid pressure on his heel and sacrum. What should be included in the S? Gas exchange, risk for Scenario 3 Change to simple Wash and glove hands Verify call light/bed safety precautions Administer pain meds Scenario #5 Encourage to ambulate w/ assistance to void if needed Peripheral neurovascualr dysfunction: False, Viola Cumble Seek clarification Pain - increased Draw digoxin Vital sign assessment Review plan Assist pt Retrieve cast removal tool Tom Richardson Wash hands and don PPE Reassess pt Sensorium - normal, - Acute pain After two hours, Mr. Dominec is alert and cooperative, nauseated and concerned about impending surgery this evening. Impaired Skin Integrity, Risk for False Initiate IV fluids to peripheral site Assess Mr. Martinez's willingness to learn. Use therapeutic communication/Active Listening Scenario 1
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