VS reassessment Impaired mobility, risk for The patient`s mental status is, stable; she is awake, alert, and oriented. She was admitted yesterday for stabilization of her glucose levels, and assist her with lifestyle modification. Ask Mrs. Whitmore Joyce Workman, Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. -Check the chart for the presence of a DNR order to provide the code team The nurse has Ms. Horton in the wheelchair ready to be taken down to the lobby by the UAP. Assess the injury for presence of necrotic tissue and amount of exudate. Notify Dr. of change Vital signs taken Start studying swift river med surg. Call for code Scenario 2 Scenario 3 Teach pt. Scenario #5 Medicate Initiate I&O Assess for fall -Provide PRN pain medications indicated. Fall Risk - increased 1-Introduce and sit down by the patient's bedside Ask Mr. Jones Do not probe Obtaintelemetry What order are you providing the information to the receiving nurse? Educate pt. Pt. Check monitor Remove infiltrated IV Explain to the pt. Scenario 3 Notify the HCP Offer masks to visitors Monitor neurovascular status assessing skin color, temp, sensation and pulses above amputation. Chronic Pain: False Scenario #1 Scenario #4 Document Swift River Maternal-Newborn; Deanna Concept Map Assignment 1; Pain - normal Don PPE Contact HCP if pt status does not improve Scenario 2 Kenny Barrett Mrs. Martinez is visiting her husband, who appears to be ignoring any attempts at conversation. Asses Mr. Wright's willingness Assess Ms. Horton's Pt and family should verbalize understanding of d/c instructions Infection, risk for, Scenario #1 Take VS now and Q4 hrs Psychological Needs: Increased acuity Contact IV team -Tell the patient that dressing must be changed, 1-Put a mask on yourself Begin fluid and electrolyte Scenario #2 Administer digoxin Request the uncle come Scenario 3 Don clean gloves and removed the old dressing. Serum Sodium Remind staff that Universal Precautions are practiced at this hospital for all pts regardless of known ID's. Sulfamethoxazole 800mg, Trimethoprim 160mg (Bactria DS) 1 tablet PO daily for 10 days 5.) Remove the dinner tray Sarah Getts Request order 4. Contact head RN Bleeding, risk for: True Study with Quizlet and memorize flashcards containing terms like Linda Pittmon, Kenny Barret, Joyce Workman and more. Obtain IV access and draw initial labs Evaluate understanding Her temp is 100.8, BP 100/62, P 92, R 21, SpaO2 91. Scenario 3 Safety- Scenario 1 Explain the necessary procedure Relocate pt. Infection, risk for, Scenario #1 Health Change: Increased acuity Stop the pt. Evaluate understanding Scenario #4 Wash hands prior to entering the room CK-MB Teach pt. Provide comfort Scenario 5 Notify social services Bleeding: False Pain - increased Imbalanced nutrition Assess Ms. Horton's Scenario #5 After two hours, Mr. Dominec is alert and cooperative, nauseated and concerned about impending surgery this evening. Check I/O for possible dehydration Deanna Concept Map Assignment 1. Full assessment Bring the family in Review medication on O2 She also takes Metformin to control her Type 2 Diabetes. Advanced Medical-Surgical Nursing New Patients Swift River. Complete assessment Inform & educate spouse Course Hero is not sponsored or endorsed by any college or university. Disturbed thought process: False Start secondary IV Readiness for self-care enhancement: True If pt. Scenario 2 ", Scenario 1 Evaluate/modify mobility plan, Physiological- Notify HCP Risk for injury: True, Scenario 1 Auscultate lungs Call rapid response -Gas exchange Evaluate medication Perform neuro assess Full assessment patient`s vital signs are BP: 152/90, P: 101, R: concerned about blood glucose and her HbA1C. Therapeutic communication w/ pt Scenario 5 Grieving Pain Level: Increased acuity Provide initial Assess/inspect Ensure side rails Document necessary Reassess VS & obtain UA Re-apply new sterile dressing. Scewl Swift River Nursing 100. . The CODE-blue team arrives w/ a crash cart, Physician, anesthetist, and 2 critical-care nurses and 1 respiratory therapist. & family Scenario 1 Give 1 mg of Atropine, IVP as ordered by provider Perform rapid assessment Apply restraint Describe the situation and what you did to deal with the situation. Encourage pt. Ensure documentation Full assessment Place pt. Pain Level - Increased Pain Level: Increased acuity Impaired comfort: True BUN Wash & glove Deficient knowledge Apply fall risk Provide Mophine Sulfate 4 mg IV Impaired comfort Reinforce the risk Scenario 4 1-Enter the room, perform hand hygiene, and cancel the call light Reduce stimuli in the pt room 2-Recognize patient is in respiratory distress with an unknown etiology Evaluate learning Reinforce need Check physician Explain the necessary Check proper positioning Review PCA pump history 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. Electrolyte imbalance, risk for: True Document & inform -If concerned about the accuracy, take BP with a manual cuff Contact HCP, Educational - increased Inform and educate spouse of dietary orders Start O2 @ 2LNC Ineffective health maintenance ShannonLamb1. Ensure documentation of time and events of RRT Assess Mr. Martinez's willingness to learn. Document consults, Educational - increased Her last K was 3.2 mEq/L. Encourage Mr. Dominec to discuss w/ his partner his best tx options. Call Mr. Jones's children year-old female who presents to the Diabetes Clinic with a new. Medicate w/ Demerol 100mg w/ Phenegran 25mg IM prior to dressing changes 5.) - Health Change - increased Nutrition consult Safety- Fall, Risk for: True Assist anesthesia Obtain translator She has sleep apnea, and she brought her CPAP machine. 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. 4-Offer to assist in completing an advance directive Check leads to ensure they are in the correct place What should be included in the S? Approach resident Scenario #5 After 24 hrs, Ms. Gestalt fever and chills have subsided but now states she is feeling like her cast is too tight Reassure the pt. Use therapeutic Anxiety: True Scenario 5 joyce workman swift river quizlet joyce workman swift river quizlet. - Psychological Needs - normal Isolation precautions: False Scenario 1 She has been documented as being obese, new onset hypertension, polyuria, and a rash on her abdomen. Restart IV Review labs Fall Risk: Increased acuity Scenario #5 Don PPE Scenario 3 -Check the pulse ox on your finger Scenario 2 Contact radiology Start O2 100% Infection, risk for, Scenario#1 Evaluation pt. -The patient is unable to process the event so far Reassess pt's VS's and pain level Obtain translator Begin continuous IV with NS @ 125 mL/ hr. Disturbed energy field Contact HCP Don 2nd set Don new gloves Impaired urinary elimination -Determine if drainage is increasing - Health Change - increased Scenario 4 has a foley -Inform Mr. Goodman that he must fill out a form requesting the medical records Collect stool Use therapeutic communication/active listening Administer pain medications Ms. Cumble states that she has not had a BM for three days Body image disturbance: False Linda Pittmon Room 304 Glucose level? The next day, he tests positive for COVID-19 and his condition has deteriorated as he is now in respiratory distress. Assist pt. 1 Ask for a copy of the advance directive Joyce Workman 12. - Pain - normal Inform his partner that everything is being done to keep him comfortable. Contact charge nurse - Impaired tissue perfusion Ensure pt. Apply O2 Risk for Infection: True Psychological Needs: Normal acuity, Physiological - immediately. Establish and IV line Impaired mobility - Ineffective health maintenance Bleeding, Risk for: True Notify family to self-isolate for 14 days She was admitted yesterday for stabilization of her glucose levels and to assist her with lifestyle modification. Mr. Richardson is requesting assistance to ambulated to bathroom Virtual Clinical- Swift River Week 4. Use therapeutic communication/active listening Assess pain and rhythm Q15 minutes Document teaching moment, Educational Needs: Increased acuity Upon entering the pts room, he is threatening to go outside and smoke, agitated and demanding to be d/c'd to have a cigarette. Initiate IV heparin Scenario #4 Grieving: False Scenario #3 MCQs Set 1. Thermoregulation Offer assistance in providing more information about treatment options for newly dx AIDS pts. Tim Jones 8. Mr. Raymond is stabilized w/ RRT. VS: BP 92/58, P 102, R 30 and labored, T 101.3, SaO2 91%. - Psychological Needs - normal, - Disturbed body image 156 terms. Reassess pain Offer masks Marcella Como 7. Assessment of bowel movement Infection, Scenario #1 Fall - increased The labs return w/ digoxin level of 10.5 ng/mL, K 5.3 mEq/L. What are your views, please? Impaired verbal communication, Scenario #1 -Use a temporal or tympanic thermometer, if available, 1-IV fluid challenge/bolus Grieving: False Full assessment Contact HCP Wash and glove hands Scenario #2 Impaired tissue perfusion: True ambulate Ineffective Renal Perfusion, Risk for True Scenario #2 Report this activity, Bleeding, risk for Evaluate pt's understanding Remind pt. Attempt to orient to person, place and time Perform circulatory Infection, risk for. Risk for injury at home, Scenario #1 Fall Risk - increased -Apply new probe cover to probe before assessing temperature Joyce Workman Room 301. Educate pt as to why he cannot go outside and smoke Assess whether or not Scenario 2 Scenario #2 Troponin 1.0 mg/mL Health Change: Increased acuity View VCBC Glucose Regulation Swift River.docx from NURSING 246 at Colorado Christian University. Upon assessment, you determined that she is confused to person, time, and place but is easily directable. Ms. Getts is being transferred as an emergency to Critical Care. Vitals? Check the foley Wash and glove hands Complete incidence report, Educational - increased Dressing change q 24 hours to RT thighs and rt shoulder. Don clean gloves Assis pt. 3 terms. 500 mL NS Reassess pt. about Fall Risk - increased Educate the family regarding intervention and support for Ms. Horton Provide emotional support Discuss physical Offer bedpan Full assessment Sensorium: Normal acuity, Physiological- Fall Risk - normal Deficient knowledge: True Paroxetine (Paxil) 30mg PO everyday. Establish when the cardiac event time began When the HCP 10 terms. Concepts of Nursing IV 100% (3) Swift River Joyce Workman scenario. Scenario #2 Check for breathing Explain to pt. Assess pleurovac Prescribed medication for anxiety must be administered Initiate a second 18g IV CK-MB 6.8 teaching 5-Notify the Provider of the patient and family's inquiry on next steps Acute Confusion True Alert? Transport pt to cath lab we/ cardiac monitors This information is HIPAA protected and you cannot share anything w/ them. The wound has been sutured and is not and open wound/stump. Empty foley Explain the tx plan for the pt Provide comfort He states, "thiss is not serious." Ensure there is a full Provide pt hx of event to team Call HCP for change in health status and receive orders for anxiety medication Note time when -Orient patient to bathroom with specifics Fall, Risk for True Risk for infection, Scenario #1 Sterile NS wet-to-dry dressing changes daily 2.) His HbgA1c is 10.6%. Provide a few chairs if possible for her family to also be comfortable - Impaired skin integrity Ask if the pt understands the procedures scheduled for this AM Administer IV ABX Full assessment & family should Reapply restraints Psychological Needs: Increased acuity Therapeutic Communication 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 Assess pt and family readiness to learn Perform initial assessment Full assessment Do not disturb Scenario 1 Ask pt. Scenario #3 Re-assess pt & VS, Educational - increased Psychological Needs - normal -Assure patient that she is safe in the hospital, and you will not leave her Fall Risk - normal Scenario 3 Scenario #5 Fall, risk for: True Head-to-toe Treat pt. She is 2 days post-op. Pain Level: Increased acuity Provide supplies and needed instructions Document all findings Pain level: Increased acuity Explain to pt. Your responsibilities are: Scenario 1 Ensure room was cleaned The rt heel demonstrates a blister 2cm x 1cm w/ clear fluid noted. Check on labs 2-The patient has survived a mass shooting Sensorium: Normal acuity, Physiological- Deficient fluid volume, risk for Scenario 5 Place pt on PCA pump Scenario #5 93 terms. -Ask the patient if she has reviewed her advance directive recently. Place pt. She was admitted yesterday for . Check for breathing and carotid pulse Use therapeutic Sign additional They wanted to know and pressure you for the information. Administer pain meds mary_heath32. Post-op assessment Psychological Needs: Normal acuity You return to the break room on your floor. Provide morphine Tissue integrity Notify charge nurse that d/c will probably not occur today. Scenario #3 Notify lead RN/Dr. Request possible change in medication and more frequent VS checks Perform circulatory evaluation - Fall Risk - increased -Administer the hydromorphone hydrochloride Mr. Raymond, COVID-19 positive, in severe respiratory distress, RRT called Deficient knowledge Scenario 5 assessment Interviewing pt. She has well-controlled hypertension with Losartan (Cozaar) 50 mg q daily. VS & head-to-toe Document results Notify family as to when they may come and visit, Educational Needs: Increased acuity Health Change: Increased acuity Educate pt & wife Reassess pt's VS Pain - increased Bleeding, risk for: False lOMoARcPSD|7327774 New Patients Swift river med . chp 19 managerial accounting connect. Ensure informed consent for procedures is signed . Linda Yu 2. -Record what and how much the patient eats CBC, CMP, Blood culture x 2, Hgb A1C 3.) Document Scenario 5 Scenario 3 Impaired skin integrity, risk for -Speak slowly in a normal tone of voice Scenario #5 Don gloves & assist pt. 3-Notify the physician that the patient may be suffering from alcohol withdrawal. 1. The nurse has another high acuity admission that has just arrived from the ER. Reassess effectiveness -Have TDD device on hand Compromised family coping Deficient knowledge Scenario 5 Check time Call HCP Peripheral neurovascular dysfunction: True. Ineffective self-health mgmt: True Wash and glove hands -Make sure the room temp is 84.0 F/29.0 C Assess VS & UO Construct dietary consult Post op day 3 time for dressing change stump. Deficient knowledge Macro Final - Quiz 4. Ask charge nurse, Educational - increased Ineffective self-health management: False Scenario 1 She is 85 years old and has a history of osteoarthritis and cataracts. Stay with pt. Wash hands Inform pt about the progression and risk a PCP infection has for a pt w/ AIDS. Assess Mrs. Workman's understanding Call Report, Educational - increased Pain - normal Assist w/ applying ECG leads Scenario 1 Fall Risk - increased Assist Ms. Horton Assist w/ airway mgmt Escort pt. Gather supplies Meet with daughter Provide report, - Educational - increased Fall Risk: False Safety- Monitor for adverse effects 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. Scenario #5 Obtain translator Explain to the pt. Full assessment Obtain informed consent Scenario #4 Intubated by Impaired mobility, risk for Psychological Needs - increased Evaluate learning Fear: True Obtain VS Using therapeutic Magnesium Educational Needs: Increased acuity Assist anesthesia Neurological: Normal acuity Fall, risk for -Assist patient in performing hand hygiene Reinforce past Put an arm band - Ineffective breathing pattern. 4.) Report Mr. Martinez's emotional distress to case management Deficient knowledge 4-Orient arriving family member to the situation, and explain importance of remaining with the patient Scenario 5 Wash hands Notify the HCP using SBAR Notify respiratory therapist to begin tx The pt continues to be combative while attempting to initiated the CPAP trial.
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