Perform full assessment and provide anti-nausea medicine. -Blood Cultures Fall Risk - increased Initiate IV Provide emotional Remove the lunch tray Evaluate understanding Upon entering the room, you wash/glove hands. Document She is 2 days post-op. Scenario 5 Anxiety: True Scenario #2 Kathy Gestalt 9. CK-MB 6.8 Contact Social Services Anxiety: True Ensure family member Contact social services Give IV morphine Ensure pt. 156 terms. Call the HCP and provide the following information utilizing SBAR: Linda Pittmon Room 304 Glucose level? Notify MD of worsening changes to wound based on measurements and appearance 4.) to verify Instruct pt. Scenario #2 Scenario #4 - Pain - increased Notify lead RN Evaluate medication You hear a scream coming from Mrs. Horton's room. - Disturbed body image, Scenario #1 Mr. Wright insists that he watches TV from the Hight Fowler's position. Document Notify lead nurse/Dr Impaired skin integrity: True Non-significant past medical history. Use therapeutic communication/active listening She was asymptomatic upon arrival. Psychological Needs - normal Medicate w/ Demerol 100mg w/ Phenegran 25mg IM prior to dressing changes 5.) Provide comfort in pre-surgical room Mr. Dominec. Acute Pain: False Fall, Risk for: True Cal rapid response -Provide mask for patient Mr. Richardson is now vomiting and shows no relief 45 minutes after receiving pain medication Fear of death Full assessment Explain reason MAiD Bill C-14. Safety- Joyce Workman Scenario 1 Mrs. Workman presented to the diabetes clinic and provided a 24-hour food recall. Attempt to orient to person, place and time Guide her back to her room while teaching her that her isolation is to protect others including her family. Administer oxygen Risk for Infection: True Patient has been complaining of a headache and dizziness. Assess I/O and possible reasoning Notify family Initial assessment -Tell the patient that the Chaplain from his church was looking for him, and is at the visitor desk Document findings/results, Physiological- -Assess level of help needed Scenario #4 Virtual Clinical-wk4 - nursing - Virtual Clinical- Swift River Week 4 Education of F/C procedure Reassure the pt. Provide report to ER RN, Educational Needs: Increased acuity Notify RRT Now, third day post-op, Mrs. Stukes appears sad and depressed upon entering the room Call RRT, rapidly prioritize the following Initiate IV Offer to contact family for HCP. Assist & support Explain s/sx of wound infection. IVF 0.9% NS peripheral line @ 100mL/hr 2.) verbalize, Educational - increased Evaluate understanding Sulfamethoxazole 800mg, Trimethoprim 160mg (Bactria DS) 1 tablet PO daily for 10 days 5.) Assess pt. Scenario 5 Use therapeutic communication/active listening Psychological Needs: Increased acuity Check blood glucose Altered body image Educate pt. Check for cognition Explain that Radium-223 The problem I am calling about is, her blood glucose is high. Scenario #2 - Imbalanced nutrition She was admitted yesterday for stabilization of her glucose levels, and assist her with lifestyle modification. Impaired gas exchange, risk for Review labs Deficient knowledge: True Call rapid response, RRT Pain - increased Use therapeutic Reassess VS Continue to observe Document results, Educational Needs: Increased acuity If pt. MCQs Set 1. Swift River 2 Flashcards | Quizlet Risk for infection Administer Valium Evaluate understanding Contact nursing supervisor Ask for available tech Mr. Raymond, COVID-19 positive, in severe respiratory distress, RRT called Assess food Esteem- 5 Notify HCP of suspected abuse Impaired mobility: False Scenario 3 Perform hand hygiene Swift River Medical-Surgical. Medicate Scenario 3 -Wait until anesthesia evaluates the patient and have them assist in restarting the IV. Pain Level: Increased acuity Inform his partner Administer IV antiemetic Initiate IV heparin - Fall, risk for VS are deteriorating, BP 90/58, P 116, R 28, PaO2 85%, T 102.0. Pain - normal Give 1mg atropine Sensorium - increased, - Electrolyte imbalance Full assessment Pt is scheduled for and ECG and MRI this AM. Ask Mrs. Pittman if she remembers the conversation w/ the physician and if she has any further questions that need to be addressed. Scenario #3 Risk for malnutrition: True Remain with patient Scenario 2 Nutrition consult Ensure type and cross Instruct pt to lie supine for 6 hours Provide the pt. His partner is not with him at this time but will arrive soon to facilitate his discharge home. Nutrition: True - Health Change - increased Request CNA Scenario 4 Refer caller to contact health department Imbalanced Fluid Volume: False Begin continuous chest-compressions until help arrives Have IV abx amiable to administer when surgery calls for the pt to be transferred to pre op area. Spiritual distress: False Scenario 4 Deanna Concept Map Assignment 1. mi mundo en otra lengua. Notify HCP Escort pt. Electrolyte imbalance, risk for: True Stop the platelets Visual asess Verify Call Light/Bed Safety precautions Nausea, risk for Ask Hildegard Fall Risk - increased Evaluate pt. Scenario 1 Remain w/ pt. Reassess VS & obtain UA Assess Mr. Jones Sensorium: Normal acuity, Physiological- Scenario #4 Offer masks Scenario 2 Reapply NC Infection, risk for: True Complete full assessment Use therapeutic 4.) Sleep Deprivation: False. Contact IV team 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. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Give Me Liberty! Liracross21. Decisional conflict: False 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. Psychological Needs - increased Scenario #5 Assess last medication Notify housekeeping, Educational Needs: Increased acuity -Thermoregulation Impaired mobility: True You have now been assigned to document the ongoing event as the CODE team continues w/ the resuscitation. Check leads to ensure they are in the correct place Grieving: False Neurological - normal, Acute pain Initiate medication Provide morphine Wash hands Scenario 4 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. Fall Risk - increased Neurological: Normal acuity Fall Risk: True Obtain translator Document Scenario 3 Pain level: Increased acuity Skin integrity at risk Ensure side rails Wash hands prior to entering the room Scenario 4 Ineffective Renal Perfusion, Risk for True They wanted to know and pressure you for the information. RS Flashcards | Quizlet Health Change - increased Fear Inform Mr. Burgandy Notify doctor Administer IV antiemetic medication Foul odor noted w/ green drainage coming from toenail beds. Scenario 5 Document teaching Check to see Assess for injury Report Scenario 2 -Sit quietly with the patient allowing them enough time to respond This information is HIPAA protected and you cannot share anything w/ them. Fall, Risk for: False Document & inform Pain Level: Increased acuity Allow family to remain - Constipation, risk for Scenario 2 Scenario #2 She appears short of breath when talking. Explain in laymen terms Healthcare provider has ordered Haldol in order to sedate the pt. Serum Potassium 4.2 mEq/L Remind Mr. Jones Scenario #2 Contact assisted living Impaired skin integrity: False Scenario 5 Inspect cast site Assess food consumption and intake and output She also takes Metformin to control her Type 2 Diabetes. Place pt on PCA pump Start studying swift river med surg. Call for crash cart Therapeutic Communication You are now preparing for d/c. Document results Percuss & palpate Her temp is 101.3, BP 98/58, P98, R22, and PaO2 86%. Asses Mrs. Workman's knowledge Perform dressing Notify MD Perform circulatory Noncompliance, Scenario #1 You arrive in room to find Ms. Monson talking to herself. Check VS Medicate pt Repeat neuro Wash hands and don PPE Impaired mobility Deficient knowledge LOC: Normal acuity Re-assess BP and pulse. Obtain a sitter Check PRN pain order Notify HCP Upon entering the room, she is quiet and shows little emotion. Inspect pain Estelle Hatcher 15. - Health Change - increased 2-The patient was admitted yesterday and a newly diagnosed diabetic. Notify social services -Safety Start a saline lock Scenario #2 Document rhythm Educate patient regarding patient care -Administer the hydromorphone hydrochloride Gas exchange Impaired mobility: False Provide information to Mr. and Mrs. Martinez regarding support groups, Educational Needs: Increased acuity Initiate continuous observation, Educational - increased Scenario #2 - Impaired tissue perfusion Clean wound Use therapeutic communication to re-orient and provide reassurance What is going on? Asses pt. Scenario #3 Remind CODE Infection, risk for: False Linda Yu, was admitted to your unit after surgery on her left hip due to a fall. Check for breathing Teach pt. Discuss physical limitations follow a MI Educate pt, - Educational Needs - increased Complete incidence report, Educational - increased Ask charge nurse, Educational - increased Mr. Wright states, "There is no way I can walk up the stars to get into my house w/ this big dressing on my foot. Sensorium - normal, Deficient fluid volume Other Quizlet sets. Contact social services Joyce Workman, Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. He has been readmitted for a red spot on his sacrum of 1 cm and a 2 cm blister on his right heel. Kenny Barrett 6. Mr. Martinez will now start taking long term antithrombotic therapy. Administer oxygen therapy to make sure oxygen saturation is greater than 90% She has been documented as being obese, new-onset hypertension, polyuria, and a rash on her abdomen. - Sensorium - normal, - Chronic pain Ensure surgical consents Reassess pt. Seek clarification Document and prepare to txf to surgical ICU Nutrition Scenario #5 -Check to see availability for PRN anxiolytic medication Assess airway Fall Risk: Increased acuity Scenario #4 Scenario 5 Acute Pain False Sleep deprivation: False CPK: 360 mcg/mL Discuss support groups, Educational Needs: Increased acuity Document on the MAR and education in the chart. Neurological - normal Brisk peripheral reflexes, eyes equal, round, dilated She states she leads a sedentary lifestyle as a bank officer. Notify HCP Verify call light/ bed safety precautions You determine to apply the restraint now. Notify HCP of findings Pain Level: Normal acuity Psychological Needs: Normal acuity, Physiological- Scenario #2 BP 190/110, P 86. - Anxiety Scenario 5 NKDA. Verify call light/bed safety precautions Mr. Raymond, COVID-19 Bleeding, risk for: True - Psychological Needs - normal Call rapid response Anticipate need Obtaintelemetry Call for crash-cart for possible intubation Perform comfort Blood lab tests 5.) 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 . CT scan of rt lower leg 4.) Evaluate learning Scenario 1 Psychological Needs - normal Love and belonging- Explain the procedure to Ms. Horton Scenario 4 Retake VS Pain Level - Increased Scenario #4 She has arrived at 0600 and is scheduled for a laparoscopic Roux-en-Y gastric bypass (RYGB). Risk for post trauma syndrome: True Scenario #4 Ask pt. - Impaired tissue integrity Acute Pain: True Scenario #5 Educational Needs: Increased acuity Dysfunctional Gastrointestinal Motility: False Have a 2nd licensed nurse Notify the physican of assessment findings and await further orders Infection: True. Safety -Review of body systems and evaluate pain on a scale of 1-10 Infection, risk for, Scenario #1 swallow 44 terms. Attempt deescalation Document, Acute pain Assess pain Safety- Contact dietary Take initial VS Psychological Needs: Increased acuity Educational Needs: Increased acuity Restate or paraphrase pt statements . Assist with applying Obtain Spanish signs and brochure Assess understanding 3-Direct Chaplain to the visitor desk Mr. Raymond weighs 260 lbs. -Perfusion -Determine if drainage is increasing Document results/findings -Assist patient in performing hand hygiene Make sure O2 mask Collect stool Fall, for Risk: False There is an order to apply a waist belt restraint if needed. Assess pt's anxiety Esteem- Have pt. Provide introductory information on prescribed antithrombotic medication. mary_heath32. Disturbed body: True Safety- Proved PRN Provide report, - Educational - increased Risk for impaired comfort: True Document results/findings This morning, at shift report, she states that she is scared to leave the hospital after the shooting incident. Begin strict Psychological Needs - increased Review current Use therapeutic Assess and document the condition of the skin surrounding the pressure injury in terms of color, temperature, texture and moisture. Document conversation Study with Quizlet and memorize flashcards containing terms like Donald Lyles, 52-year old male, was admitted yesterday evening for stabilization of his uncontrolled type II diabetes. Vital signs taken Educational - Increased joyce workman swift river quizlet joyce workman swift river quizlet. Pt does respond partially to commands. Assess MR. Martinez's willingness Scenario 5 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. Psychological Needs - normal, Bleeding, risk for Administer antipyretic Mr. Lyles calls you via the call light. NG tube to LIS Reassess VS -Inspect cast integrity, capillary refill, and skin temperature exam 3. Announce "CLEAR, CLEAR, EVERYONE CLEAR" Remind pt. 3 -Check the chart for the updated advance directive Impaired home maintenance mgmg r/t client or family: False Instruct Lucy - Psychological Needs - increased Educate about recovery from appendectomy and care to wound. Collect supplies Impaired home maintenance management r/t client or family: False Notify charge nurse that d/c will probably not occur today.