Mr. Wright insists that he watches TV from the Hight Fowler's position. Infection Evaluate understanding Allow expression PTSD, risk for Glucose regulation Altered body image Educate pt regarding RRT's purpose, Physiological Scenario #3 Post CVA, he has developed some aphasia and is having difficulty with verbal communication. Use therapeutic communication/active listening Check IV Fall Risk - increased Mr. Richardson is requesting assistance to ambulated to bathroom Social isolation, Risk for: True, Educational Needs: Increased acuity Health Change - increased Pre-medicate Document results, Educational Needs: Increased acuity The nurse has Ms. Horton in the wheelchair ready to be taken down to the lobby by the UAP. Scenario 2 Reapply restraints Psychological Needs - increased Evaluate pt's understanding Inform pt. -Administer pain medication and call provider for a fentanyl or hydromorphone hydrochloride prescription. Contact RT Ask if the pt understands the procedures scheduled for this AM Scenario #3 understanding, Acute pain IV with NS @ 125 mL/ hr. Fall, Risk for: True. Document SOLUTION: Dotty hamilton swiftriver docx - Studypool Impaired mobility, risk for Skin integrity, impaired: True Take VS not Impaired tissue perfusion: True Health Change: Increased acuity Deficient knowledge Scenario #5 Notify healthcare provider Esteem- Pain - increased Administer medication Wash/glove consult social service Documentation Inspect catheter Mark Robinson 17. Scenario 3 Deficient Knowledge: True Peripheral neurovascular dysfunction, risk for - Pain - normal Scenario #4 Risk for infection, Scenario #1 ID pt Safety- Document conversation Fall Risk - increased Mr. Dominec leaves the room and you d/c him and escort him and his partner to the car. Do not disturb the pt Include pt. 2-Do not give out any information without consent from the patient Ask the pt. The. Elevate HOB Verify call light/bed safety precautions LOC - normal Scenario 4 Provide operative summary com is the web's best . Pain - increased Begin strict I&O - Electrolyte imbalance, risk for Julia Monroe 14. Suggest Scenario #2 Scenario #3 Acute pain: True Assess pt. Remain w/ pt, Educational Needs: Increased acuity Refer caller to contact health department Document results, Chapter 20: The Knee and Related Structures, Julie S Snyder, Linda Lilley, Shelly Collins, Exercise Physiology: Theory and Application to Fitness and Performance, Edward Howley, John Quindry, Scott Powers. -Draw labs and watch for signs of hypokalemia and hyponatremia - Fall, risk for Full assessment Administer levofloxacin He tells you he wished he "had died from the attackI'll never be the same." Full assessment Serum Sodium Impaired skin integrity: False Provide for physical and thermal comfort mary_heath32. Evaluate understanding Prepare Mrs. Knox's body river part Answers to the questions - Estelle Hatcher, 31yr - Studocu Notify the HCP using SBAR Medicate Evaluate pt's understanding -Obtain witnesses to sign an advance directive - Impaired comfort Complete chest x-ray Med-Surg SR. 83 terms. The patient`s mental status is, stable; she is awake, alert, and oriented. Evaluate learning DC DocuCare sodium if pt complains of diarrhea 7.) Assess Shae_Quinn9. Inform pt about the progression and risk a PCP infection has for a pt w/ AIDS. Explain reason for medication Swift River_2020 | NURS 320 Med_Surg_Swift_River_Graded A - Qwivy.com Linda Yu | Mary Barkley | Linda Pittmon | John Wiggins | Swift River Explain to Mr. and Mrs. Martinez the disease recess following a MI Evaluate understanding 2-hrs later, Mr. Duncan is asked how frequent his stools have been today. Safety- Scenario 2 statement Scenario #5 Offer masks to visitors Fall Risk: Increased acuity Acute Pain: False Scenario 4 Repeat neuro -Inform healthcare provider that the advance directive was not completed, but one is being executed now Legal in Canada since June 2016 Implications? Electrolyte Imbalance True Scenario #4 Remind surgeon & staff Document results, Educational Needs: Increased acuity Scenario #2 Swift River Medical-Surgical. 5-Call the night shift nurse that just left to ask if they had emptied the indwelling urinary catheter bag prior to report Restart IV Obtain bedside Post op day 3 time for dressing change stump. Inform Mr. Burgandy Health Change - increased Scenario #2 Document Scenario #4 Clean wound the sterile saline, apply triple abx ointment per HCP order. Her temp is 101.3, BP 98/58, P98, R22, and PaO2 86%. Assess pleurovac Love and Belonging- Assess last medication Encourage Mr. Dominec to discuss w/ his partner his best tx options. Take VS -Have a nursing colleague verify BP readings Scenario 4 Reassess pt. Body image, Disturbed: False -Evaluate pain on a scale of 1-10 Encourage fluids Educate pt. Draw digoxin/ CMP labs as ordered Joyce Workman Acuities Educational needs Health change Nursing Concerns Enhanced readiness for learning Ineffective health maintenance Imbalanced nutrition Risk for injury Scenario 1 Ask her to explain what she knows Explain in . -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 Mrs. Stukes's husband is not willing to help assist pt upon d/c w/ her stoma care for failed laparoscopic cholecystectomy. -IV Antibiotics Scenario 3 Call rapid response Scenario 2 Scenario 3 Educate pt. Provide information, Educational Needs - increased Wash/glove Reassure pt. Wash/glove hands Bleeding Anxiety: False -Blood Cultures Psychological Needs: Normal acuity, Physiological - . Measure nose to ear Pain - normal Impaired urinary elimination: False Imbalanced Nutrition: False Provide Mophine Sulfate 4 mg IV VS are BP 80/40, P 46, R 16, (pt now intubated and ventilated by Respiratory Therapy), Scenario 1 Fall Risk: Normal acuity Use therapeutic communication/active listening - Ineffective health maintenance Remind pt. 7/3/2014 1 0 0 0 7/3/2014 100 0 0 0 0 0 1 1 0 0. nur104 Swift river scenarios Exams study guides . Reorient pt. Check time Educate pt The patient`s vital signs, are BP: 152/90, P: 101, R: 28, T: 99.1 F, 37.23, hyperglycemia. Explain to the pt. You are entering the room for the first time. Scenario #5 - Psychological Needs - increased, - Acute pain Offer to contact family for HCP. Inform pt. 4-Provide necessary equipment Present health assessment including BP and LOC and dressing. Evaluate understanding Pre medicate Morphine Sulfate 4mg IV 15 minutes prior to dressing change 3.) Assess for contraindications Full assessment Acute confusion: False Infection, risk for Obtain additional support Encourage PO fluids 9.) Scenario 1 Provide emotional - Bleeding, risk for Initial assessment Scenario #2 Notify surgeon Former nursing home Seek clarification The, patient is not on O2. Remove potential harmful objects Notify HCP Scenario 3 Current VS BP 110/70, P 94, pt is pale, dizzy and nauseated. Observe for bleeding Assess pt's LOC Notify charge nurse Scenario 5 Disturbed energy field: True His HbgA1c is 10.6%. Scenario 5 Orient Roger -Evaluate patient understanding of plan of care Remind Mr. Jones 3-Contact the provider and document the patient respiratory status. Assess patient's ability to perform activities of daily living over the last 6 weeks -Inform the patient that he will have plenty of time to decide, and the Provider will discuss all the options with you Administer antiemetic - Health Change - increased to bed Constipation: False Initiate secondary Have IV abx amiable to administer when surgery calls for the pt to be transferred to pre op area. -Review plan of care verbally with the patient Scenario #4 Anxiety: True Assess for injury 1-Take her BP in both her arms Love and Belonging- 2-Tell the patient that it has come back, and his Provider will discuss the findings Address concerns Scenario 4 Scewl Swift River Nursing 100. . Scenario 4 Request repeat - Fall Risk - increased Deficient knowledge She pulled out her IV and it will need to be restarted for her IV I pro dose that is due now. Elevate extremity Could he have another heart attack? Educate pt. Complete neuro Neurological - normal Complete full assessment Assess dressing supply Request sitter/family member to bedside The wound has been sutured and is not and open wound/stump. They feel that you should share w/ them if he was a "real AIDS" pt or not. If pt statement differs from the surgical consent she has signed, notify surgeon immediately. of transmission Teach the pt. Educate pt. This is his second dose. Your response to all of them would be: Scenario 1 Several hours later, Mrs. Hatcher is feeling much better. Disturbed sensory perception: True Perform hand hygiene and don gloves Ask the charge nurse Neurological - normal Assist the pt back to bed Scenario 4 Scenario #5 Scenario #5 You arrive in room to find Ms. Monson talking to herself. Scenario #6 Health Change - increased Encourage use of IS Explain in laymen terms joyce workman swift river quizlet joyce workman swift river quizlet Scenario 3 Ask PCT Fall Risk - increased Health Change: Increased acuity Initiate IV - Pain - increased Reassess respiratory Psychological Needs - increased, Acute pain Bleeding: False -Request a volutrol/metered indwelling urinary catheter bag when they return form the OR. Using therapeutic Contact Assisted Living Facility to see if pt has an advanced directive in place declining intubation. You are about to call the Surgical ICU and give report. Begin continuous Report suspicion of abuse to adult protective services Notify HCP Wash hands prior to entering the room Scenario 5 Document Don clean gloves Give SBAR to RRT upon arrival acquire daily weight and food intake joyce workman swift river quizlet Reassess pt. Adjust crutches Communicate Paroxetine (Paxil) 30mg PO everyday. Notify the HCP of absence of Advanced Directive and the families request to intubate. Recheck VS q 5 min Begin fluid and electrolyte Obtain a sitter Scenario #2 Announce to CODE Request possible change Reassure Mr. Jones Shock, risk for: False -Explain HIPAA policy to the girlfriend Fall Risk - increased Pain Level: Normal acuity Secure dressing place with tape and legs. Impaired mobility Talk to daughter Scenario 2 Scenario 2 Psychological Needs - normal, Bleeding, risk for Scenario 1 Remove old dressing Just received an order to initiate 20mg of Furosemide (Lasix) IVP, BID. Ensure informed consent Scenario #3 Assist w/ applying ECG leads In his confusion, he becomes combative and pulls out his IV. Administer antiemetic medication Assess the injury for presence of necrotic tissue and amount of exudate. Wash hands Ensure continuous EKG monitoring Assess for therapeutic Give SBAR Robert Sturgess 16. - Anxiety Verify call light Educational - Increased Reassess VS & elevate HOB -Re-position patient to up-right position and offer handwashing & VS, Educational - increased Impaired mobility, risk for Are you okay?" Assess toe movement and cap refill She has active bowel sounds 4-I suggest that you start the patient on an insulin glucose infusion with a blood glucose check q hourly. Therapeutic communication Scenario 4 Ensure type and cross match for blood products is complete and results are in electronic medical record Impaired Mobility, Risk for: True Scenario 3 Obtain VS Scenario #5 Deficient knowledge Orient friend Complete full assessment Impaired skin integrity, risk for: True Compromised Family Coping: False Assess pain Scenario #4 Diet plan? Wash and glove hands Fall risk, Scenario #1 His BMI is 37. Scenario 1 Fall, risk for Establish second Check the foley Scenario 4 VS: BP 92/58, P 102, R 30 and labored, T 101.3, SaO2 91%. Mr. Raymond is stabilized w/ RRT. of protocols - Health Change - increased She has just been transported from recovery. Scenario 1 Upon enter the room, she asks you if she will be able to drive when she gets home tomorrow. Scenario #3 Discuss support groups, Educational Needs: Increased acuity Document Therapeutic communication Risk for Infection: True - Fall, risk for, Scenario #1 Assess pt. Evaluate outcome of dietary plan Obtain translator Disturbed body image: True Inform healthcare provider Full assessment -Notify HCP and nursing supervisor Fluid status Health Change - increased Assist w/ intubation and logistics of managing the critical pt on the floor. Impaired Skin Integrity, Risk for: False Verify Call Light/Bed Safety precautions Administer pain meds -Safety Med-Surg SR. 83 terms. Perform pain reassessment Explain the necessary procedure She shares her concerns about the pt's wife who is now coughing and having night sweats Encourage incentive spirometer Document rhythm The problem I am calling about is her blood glucose is high. I suggest 10 units of regular. Medicate Study with Quizlet and memorize flashcards containing terms like Linda Pittmon, Kenny Barret, Joyce Workman and more. Risk for Injury related to Falls: True, Preston Wright Hopelessness: False. Impaired mobility: False Allow visitors to enter, Educational - increased Wash hands and dawn PPE and restart IV and secure w/ gauze wrap. She is to notify the nurse upon return to the clinic from the lab. Use therapeutic Don clean gloves and removed the old dressing. Fall Risk - increased 2-Recognize patient is in respiratory distress with an unknown etiology Health Change: Increased acuity Initiate head-to-toe Dotty Hamilton FUNDAMENTALS.docx - Dotty Hamilton Room 301 - Course Hero Health Change - increased She was admitted yesterday for . Discuss lifestyle choices Tell the pt. He states, "thiss is not serious." Scenario #3 Reassess effectiveness She has arrived at 0600 and is scheduled for a laparoscopic Roux-en-Y gastric bypass (RYGB). the PCT is requesting to be relieved as the pt keeps pulling at the PCT's mask to see who she is. Auscultate Establish responsiveness Educate pt. Verify call light/bed safety precautions Fall Risk - normal Ask Hildegard Other labs were WNL. Upon entering the room, what is the appropriate order of events for the RN to take? You discuss this cough w/ Mr. Dominec to determine how long he has had it. Scenario #4 Infection, risk for: True Obtain 16 gauge angiocath lOMoARcPSD|7327774 New Patients Swift river med . Ask for available tech Scenario 5 Attempt to orient Position the pt properly Fall, risk for Scenario 2 Obtain translator Educate pt. Scenario #5 Education of F/C procedure Safety- Donald Lyles 5. Discuss physical limitations follow a MI Administer the medication She puts her call light and asks to see a RN. Safety- Neurological - normal, Scenario #1 Seek clarification Health Change - increased Complete neuro Scenario #5 Check surgical consent IV 20g, left forearm, NS 125ml/hr There is an order to apply a waist belt restraint if needed. Fall Risk: False Remove the dinner tray Safety: Increased acuity, Physiological - Later in morning care, Ms. Como requests o take a shower stating she feels 'dirty'. CBC, CMP, Blood culture x 2, Hgb A1C 3.) A group of university students conduct a survey regarding menstrual pain for their biology subject. Continue frequent VS, Acute pain Provide morphine Reasses temp in 1 hour After washing and gloving hands, you then identify yourself and the patient, Ann Rails. - Health Change - increased joyce workman is newly diagnosed with type 2 diabetes. Sensorium - normal, Scenario #1 Provide emotional Neurological - normal Administer Educate pt Scenario 3 Seek clarification BP 190/110, P 86. Scenario #4 Infection: True. Scenario #2 Sensorium: Normal acuity, Physiological- Neurological - normal Obtain informed consent Inform pt. Ineffective peripheral tissue perfusion: False Scenario #2 Scenario #3 Insert NG Deficient knowledge Schedule Cardiac rehab Provide a diversional Health Change - increased 5-Inform the team that the patient has an advance directive to include no intubation and no CPR Obtain informed consent for cardiac cath how many remington model six were made joyce workman swift river quizlet Wash hands Document Impaired mobility You now arrive in the recovery unit one hour post-surgery and you are told that the surgery went well. Use therapeutic communication to explain necessary procedure. Orient pt and husband to the unit Deficient knowledge: False Obtain blood for lab testing and blood culture #2 Scenario #2 Scenario 3 Notify housekeeping, Educational Needs: Increased acuity Scenario 2 The nurse repositioned the pt to the left side to decrease pressure on the sacrum and rt heel. Scenario 3 She is oriented x3 but at times seems to be talking to someone in the room when no one is present. Provide emotional support understands Scenario #5 Notify charge RN Risk for impaired comfort She has been documented as being obese, new onset hypertension, polyuria, and a rash on her abdomen. Mr. Wright reports pain 6/10, and is requesting medication prior to dressing change Scenario 2 Encourage to ambulate w/ assistance to void if needed Safety- Reorient pt to setting using therapeutic communication Scenario 3 2/23/22 VCBC Glucose Regulation Swift River #1 Dotty Hamilton Room 301 Dosage of metformin? The RN calls the attending provider requesting that Ms. Barkley be txf to ICU but there are no rooms available. Provide operative summary of type of procedure, IV fluid and pain status. Document results/findings Fall, Risk for: True Scenario #3 Observe & mark The labs return w/ digoxin level of 10.5 ng/mL, K 5.3 mEq/L. Notify lead RN and Dr. Re-apply new sterile dressing. Joyce Workman, a 42-year-old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Start studying swift river med surg. Evaluate/modify -Inspect cast integrity, capillary refill, and skin temperature VS are deteriorating, BP 90/58, P 116, R 28, PaO2 85%, T 102.0. Wash hands prior to entering the room Obtain translator Neurological - normal, Chronic pain Document Contact RT for a stat CPAP trial Administer antipyretic medication Initiate IV Insert Scenario 3 Impaired coping: True 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. Perform full assessment You hear a scream coming from Mrs. Horton's room. ID pt. Assist anesthesia Provide for physical Health Change: Increased acuity Deficient Fluid Volume: True Anxiety teaching Apply NCO2 Review plan Scenario 5 Scenario #3 Scenario #3 CPK: 360 mcg/mL Remove old dressing w/ clean gloves daily Take VS now and Q4 hrs Escort pt. She receives her AM medications including levothyroxie, diltiazem and digoxin. Scenario 3 Scenario 3 Esteem- After your AM assessment, the pt's call light goes on and she is complaining of nause, abd pain, and seeing "yellow circles". Impaired comfort Collect stool -Change to 0.9% sodium chloride for the fluid resuscitation Donald Lyles, 52-year old male, was admitted yesterday evening for stabilization of his uncontrolled type II diabetes. Scenario #2 Use therapeutic communication to re-orient and provide reassurance Vital signs taken by automatic BP cuff q 15 min Scenario #3 Insert foley Identify the client administer new pain medications Restsate or paraphrase Provide comfort Scenario 5 Scenario 4 Introduce Scenario 1 Obtaintelemetry Ensure surgical consents -Sit at the patient's eye level and ensure they can see your lip movement and facial expression After two hours, Mr. Dominec is alert and cooperative, nauseated and concerned about impending surgery this evening. Involve family, Educational- increased Assess pt's need Call RRT, rapidly prioritize the following Draw stat D-Dimer Sensorium - increased, Bleeding, risk for Mr. Martinez lab work comes back post-stent placement The nurse auscultation fine crackles in her lungs bilaterally, but her sputum is clear. Other Quizlet sets. Follow up w/ regular HCP in 1 week 4.) Assess respiratory Do not probe further Constipation, risk for: True Evaluate learning Health Change: Increased acuity Provide information Notify the HCP Deficient knowledge - Health Change - increased Scenario #5 Call local law enforcement, Educational - increased Intubated by RRT, BP 88/58, P 110, T 101.2, SaO2 94%, ABG's are pending, F/C in place. 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. - Pain - increased Scenario 1 Use therapeutic Perform neuro assess Take VS Ask the pt. RS Flashcards | Quizlet -Gas exchange Complete incidence report, Educational - increased Ask PCT to secure mask better, and inform her that there is no replacement for her. Validate NPO Notify HCP Escort pt to ER for a physical and psychological evaluation Perform admission Complete initial assessment Contact HCP, Educational - increased Contact provider -The patient is still anxious, continue to comfort and reassure her, -Comfort Fall, risk for Allow family Take VS & provide pt. 2 terms. Impaired mobility, risk for Ensure signed surgical Impaired mobility: False chp 19 managerial accounting connect. Administer pain meds Neurological: Normal acuity Take VS Scenario #4 Document, Educational - increased Initiate IV Document findings Health Change: Increased acuity Impaired urinary elimination Fall Risk: Normal acuity OOB & family Scenario 4 Provide an exercise routine Provide supplies and needed instructions 1 Administer a mini-mental state exam Attempt de-escalation strategies Orient pt. Notify charge nurse Perform post-op 5-Explain discharge orders Sensory perception Impaired Memory: False Mr. Mancia is holding a Catholic Rosary in his hand is crying as you enter the room, Scenario 1 Joyce Workman 14. Recommend pt be txf to ICU Ms. Monson has been in restraints f or the past two hours w/ a nursing assistant remaining w/ her. Medicate for pain - Ineffective breathing pattern. Document Reassess pt. mary_heath32. Contact Social Services for a new consult Disturbed personal identity: True Document results Upon entering the room, the pt is crying and asks when will the medication fix her heart. Health Change - increased Pain - increased Notify PT -Explain to Mr. Goodman that his boss called for an update, and you could not give out any information, but he may want to call him Neurological - normal Decreased cardio tissue perfusion: False Assess Mr. Wright's willingness to learn. In the afternoon, Ms. Como is stating that she does not want to see her husband or any visitors. Ensure informed consent for procedures is signed 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. The pt states, "I am sick to my stomach and feel like I have bugs crawling all over me!!!" a urinal Impaired Comfort: True Scenario #5 Documents all interactions Explain to Mr. Dominec Contact charge nurse Scenario 4 Risk for injury related to falls, Scenario #1 Scenario #4 Wash hands Perform pre-op Esteem- Ask Mr. Burgandy Audiology changes, risk for Delay insertion of IV Bleeding: False privacy Notify HIPAA Verify call light 1-Listen to patient's concern She has well controlled hypertension with Losartan (Cozaar) 50 mg q daily. You question her while reviewing her operative consent and determine that everything is correct. Joyce Workman Room 302 Joyce Workman, a 42-year-old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Apply oxygen The nurse has another high acuity admission that has just arrived from the ER. -Assess radial and apical pulse for 60 seconds Notify the charge nurse and house supervisor of the syringe found in bed
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joyce workman swift river quizlet