Procedure is scheduled Restart IV Witness daughter Risk for malnutrition: True Comfort the pt VS & head-to-toe Scenario 3 Monitor aPTT Sensorium - increased, Bleeding, risk for Impaired skin integrity, risk for Assist pt Use therapeutic Check the client Kenny Barrett, 64 years old, was admitted for observation of initial administering of BP his treatment with blood pressure of 220/124 after visiting his doctor for a routine physical. jasmine_347. Wash and glove At 2200, you enter the room and the pt states pain is now 10/10 after not having any pain for 3 hrs. She is very excited about the surgery but is also apprehensive. -Assess his airway Scenario #2 Full assessment Administer oxygen Scenario #4 The surgeon added oxycodone 5mg q 4-6 hours prn pain. Fluid & electrolyte imbalance, risk for Discuss physical Evaluate learning Restart IV Educational - Increased Fall Risk: Normal acuity Mrs. Stukes's appliance is leaking for the fourth time today and has been changed and reapplied each time. Assign a UAP Reposition HOB to semi-fowler's Failure to thrive: True, Lithia Monson Address pt's skin tear You begin his assessment, and he falls back in the bed and becomes unresponsive. Safety - Give 1L NS HCP orders digoxin immune fab to be given. Joyce Workman, Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Have pt. assessment Psychological Needs: Increased acuity Scenario 3 Could he have another heart attack? Acquire daily weight - Health Change - increased Chronic Pain: False Psychological Needs - increased Scenario #4 Notify charge RN Draw stat D-Dimer Infection, Risk for: True Deficient knowledge: True Notify Infection Control Anxiety: True Noncompliance: False Document Administer pain medications Establish responsiveness Provide emotional Alteration of protective mechanisms: True. Suggest Provide comfort in pre-surgical room Mr. Dominec. Do not disturb the pt -Reassure patient -Coping Order for a Foley catheter has been obtained and Lucy Jones, LPN, is their to assist. Therapeutic communication Full assessment including both lying/standing Begin list of medications Check leads to ensure they are in the correct place -Notify Healthcare Provider of findings Educate pt. Scenario #2 Clean wound Document Mr. Dominec had his surgical procedure and is doing great. -She experienced life threatening wounds with 2 gunshot wounds, including one to the shoulder Scenario #3 Sleep deprivation: False. Meet with daughter Educate pt. Her last K was 3.2 mEq/L. Scenario 5 Risk for impaired comfort Talk with her Peripheral neurovascualr dysfunction: False, Viola Cumble Deficient Fluid Volume False Psychological Needs: Normal acuity, Physiological- Provide emesis basin -Perfusion Tissue integrity Infection risk: True Scenario 3 Alert Mr. Wright's case manager Scewl Swift River Nursing 100. . The pt has now been sedated, and RT is temporarily maintaining their saturation's w/ effective valve mask ventilation. Infection, Risk for: False Scenario #5 Psychological Needs: Normal acuity, Physiological- Request order Take VS Request sitter/family member to bedside Before this, I recommend an ABG be completed to check the patient`s pH to confirm ketoacidosis, -Intracranial Regulation Request time After 24 hrs, Ms. Gestalt fever and chills have subsided but now states she is feeling like her cast is too tight Educate pt. Scenario #6 His . Scenario 2 It is now third day post-op, the order is for Ms. Cumble to stand by bedside on both legs for 5 minutes a day, Scenario 1 Prepare Mrs. Knox's body Ensure IV access Scenario 1 Assist w/ intubation, Educational - increased Scenario #1 Assess pt's concerns Scenario 4 Fall Risk - increased He replies," six times in the past four hours". Inform the pt. Neurological - increased, Acute pain Impaired urinary elimination Scenario #2 Perform comfort Scenario #4 Ask pt. Complete full assessment Complete full assessment Impaired comfort, risk for Ms. Cumble states that she has not had a BM for three days Scenario #2 Increase supplemental O2 Vital signs are Temp 98.9F, BP 178/90, P 88, RR 18 SaO2 95% on Room air. Notify housekeeping, Educational - increased Administer antipyretic meds Scenario 5 Allow husband to make a quick one-minute visit Scenario #2 Reinforce dressing Provide emotional support Scenario 2 Make sure accurate wt. Contact RT for a stat CPAP trial Obtain telemetry set-up and take to pts room Check for breathing and carotid pulse Scenario 3 list her acuities. -Apply dry sterile dressing to IV site Scenario 5 Evaluation pt. Bleeding Neurological - normal, Scenario #1 Pain Level: Increased acuity Full assessment Perform circulatory evaluation Contact dietary Evaluate understanding Administer pain meds Scenario 5 joyce workman swift river quizlet 29 Jun. Check cranial nerves Anxiety Obtain translator Right after admission the nurse finds her walking down the hall trying to leave. Psychological Needs - normal Alert ICU Apply clean gloves Consult wound care Medicate pt. Ask surgeon Fall, risk for: True Continue strict I&O Explain procedure 4-Contact Provider for an anxiolytic medication Full assessment - LOC - normal Ensure chest tube, Educational - increased 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 . Teach pt. Ramona Stukes 17. VS reassessment Document - Health Change - increased Set up PCA Evaluate understanding Report suspicion of abuse to adult protective services Reassess pt's VS Reassess pt. Scenario #5 Alert the charge nurse that Ms. Barkley is deteriorating and you need to remain with her. Reassess pain level Evaluation pt after consult Fera/anxiety, Scenario #1 Prepare the patient for possible intubation Educate pt Document -The patient is still anxious, continue to comfort and reassure her, -Comfort His HbgA1c is 10.6%. He has been informed that for the next 18 months he should take antithrombotic therapy daily. Ms. Getts is requesting water to drink. -Tell the patient that the Chaplain from his church was looking for him, and is at the visitor desk Provide emotional support Encourage Mr. Dominec to discuss w/ his partner his best tx options. Ensure informed consent Evaluate understanding Scenario #4 Reinforce past Coptic mechanisms that have been effective 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. Explain to surgeon Have pt put on a mask Anxiety Blood lab tests 5.) Impaired mobility: False Assess food Provide a few chairs if possible for her family to also be comfortable Scenario #4 Mr. Sturgess is now declining, and family members are requesting to remain in room past normal visiting hours, Scenario 1 Mr. Wright insists that he watches TV from the Hight Fowler's position. Acute pain - Health Change - increased Report finding to HCP using SBAR. Evaluate the following expression containing percent. Assess leg Obtain and provide the ID MD contact information for him. Scenario 3 -Ensure pathway is clear 4-Orient arriving family member to the situation, and explain importance of remaining with the patient Scenario #3 Assessment of bowel Impaired comfort - Sensorium - normal, - Chronic pain Ms. Getts is now complaining of sudden sharp, substernal chest pain, very short of breath and is profusely diaphoretic. Bring the family in Mr. Raymond continues to deteriorate and becomes confused. Complete full assessment Discuss support, Acute pain Collect pre-op labs Vitals? Notify lead nurse/doctor Your response to all of them would be: Scenario 1 Remind staff that Universal Precautions are practiced at this hospital for all pts regardless of known ID's. joyce workman is newly diagnosed with type 2 diabetes. (Blood to dialysis solution or dialysis solution to blood). Read PT report Use therapeutic Remind CODE team to stop CPR and check for pulse Q5 minutes Psychological Needs - increased, Acute pain Pain Level: Increased acuity Scenario 1 Scenario 5 Inform healthcare provider She presses the call light w/ questions about who her RN will be and her NG-tube. Intubated by RRT, BP 88/58, P 110, T 101.2, SaO2 94%, ABG's are pending, F/C in place. Peripheral neurovascular dysfunction: False, Kenny Barrett Other Quizlet sets. Vital signs are BP: 146/94, P: 88, R: 22, T: 99.2, PaO2: 94% Blood glucose upon admission is 340 mg/dl. Ann Rails Scenario 3 Assess the pt. Document In reassessing Ms. Monson, her VS are BP 106/82, T 98.2, P 106, R 18, SaO2 88, Scenario 1 Document Assess respiratory Pain Level: Normal acuity Verify call light Contact HCP Fall Risk: Increased acuity Provide another Have an aide sit w/ Ms. Barkley while you obtain the IV supplies and notify the HCP of her declining condition. Sensorium: Normal acuity, Physiological - Scenario 5 4-Stop the conversation immediately Encourage the HCP to consider intubation in the absence of signed DNR. Use therapeutic Obtain an order to insert a Foley catheter Impaired physical mobility Notify social services, Educational - increased Health Change: Increased acuity -Inform the patient that he will have plenty of time to decide, and the Provider will discuss all the options with you Notify lead RN/Dr 5-Use disposable blood pressure cuff Reassess pain Educate about recovery Fall Risk - increased Scenario #4 Safety: Increased acuity Neurological - increased Pain Level: Normal acuity Scenario #4 Escort pt to vehicle Set up supplies Administer oxygen therapy to make sure oxygen saturation is greater than 90% Impaired gas exchange: True -Gas exchange Assess pain Ineffective peripheral tissue perfusion: False Risk for social isolation: False, Jose Martinez Orient pt. Document conversation She states she leads a sedentary lifestyle as a bank officer. Reduce stimuli Don PPE Ask Hildegard Draw digoxin/ CMP labs as ordered Check time The nurse has Ms. Horton in the wheelchair ready to be taken down to the lobby by the UAP. Assist RT to initiate CPAP trial Check physician orders Check foley Provide comfort Scenario #2 - Ineffective breathing pattern. Scenario #3 Love and Belonging- Contact surgeon Scenario #2 Explain to the pt. Fall Risk - increased Discuss physical limitations follow a MI Talk with Mr. Jones Pain - increased Skin integrity at risk 1. Enter the room after taking VS. Explain reason Swift Water Awareness. & family Assist w/ airway mgmt Diarrhea: False The CODE-blue team arrives w/ a crash cart, Physician, anesthetist, and 2 critical-care nurses and 1 respiratory therapist. Complete head-to-toe -Test patient's vision with number of fingers, objects, etc. Contact wound care Restart pt's IV Evaluate/modify Safety- Deficient knowledge Initiate continuous observation, Educational - increased Scenario #4 Documents all findings Administer IV antiemetic medication Scenario 2 Notify the HCP Wash/glove Administer IV antiemetic Scenario #2 Don Johnson Room 306. Scenario #3 Attempt to restart IV Put on gown and mask Health Change - increased Impaired mobility: True Powerlessness: True, Robert Sturgess Auscultate lungs Scenario 5 Provide one-to-one Proved PRN Notify lead RN/ DR of new circumstances Provide comfort Nathaniel Gonzalez 15. - Fall, risk for, Scenario #1 Swift River Dotty Hamilton scenarios; Swift River Jose Martinez scenarios; Blood Therapy lesson 2 post test; Blood Therapy Exam; HESI Case Study Sentinel Event Suicide; . Document Perform rapid assessment Log roll pt. Advanced Medical Surgical Nursing New Patients Notify doctor on telemetry . Pre-op education VS are BP 128/82, P 90, R 22, T 99.2, Scenario 1 Scenario 2 Health Change: Increased acuity Wash hands & assess Don gloves NURS 320 Med_Surg_Swift_River **New Patients from 2020, Post- Covid-19 Update:** **Charlie Raymond , John Duncan, Carlos Mancia, kenny barrett, Tim Jon es, Julia Monroe, Donald Lyles, John Wiggins, Richard Dominec, Preston Wright, Tom Richardson, Joyce Workman, Karen Cole, Jose Martinez, Mary Barkley Charlie Raymond (for older swift river patients see other pdf files loaded at the bottom of . Scenario #4 Pt states she has noted some "toe pain" but that it has been <3 on a scale of 1-10. Pt. Check on labs Describe to pt. Grieving: True Sensorium: Normal acuity, Physiological- Impaired comfort Psychological Needs - increased - Pain - increased Neurological - normal Imbalanced Nutrition: False Don gloves & assist pt. Contact hospice/social work Her husband and children remain w/ her in the surgical holding area awaiting transport to the OR. When help arrives Scenario #5 Encourage pt. Impaired Tissue Integrity: True -Inform healthcare provider that the advance directive was not completed, but one is being executed now Scenario 1 Document, Physiological Psychological Needs - increased 3-Comfort and orient patient to person, place, and time. Impaired coping: True Risk for injury: True, Scenario 1 Set her up w/ a video chat w/ her family I suggest 10 units of regular. Identify the client Ensure signed surgical Release restraints/full range of motion Contact HCP, Educational - increased Reinforce provider teaching Request the uncle come 3-Have UAP gather fresh linens Check NG tube Deficient knowledge Post CVA, he has developed some aphasia and is having difficulty with verbal communication. Teach pt. Scenario 2 - Fall ,risk for Assess for pain Use therapeutic communication/active listening Scenario #4 The pain was relieved post-op. Therapeutic Communication Health Change: Increased acuity Discuss w/ pt. Psychological: Normal acuity