Teach the pt. Her pitcher has already been filled three times this shift. Document results Explain the TX Grieving: True Verify call light Acute Pain False Inform healthcare provider Mr. Raymond, COVID-19 Set up supplies Assess VS Scenario 5 Contact social services The nurse has Ms. Horton in the wheelchair ready to be taken down to the lobby by the UAP. Assis pt. Provide morphine Scenario #3 Ms. Getts is being transferred as an emergency to Critical Care. Wash hands Self-Care Deficit: False Check monitor You tell the pt you will be glad to check-on what is available for relief of his "heartburn" after you complete his physical assessment. Vitals? (Blood to dialysis solution or dialysis solution to blood). Scenario #4 Offer pt. Apply triple abx ointment to edges of wound each dressing change 3.) Ensure signed surgical Contact HCP for Nicotine patch order, Educational Needs: Increased acuity CK-MB You hear a scream coming from Mrs. Horton's room. Fall, Risk for: False Teach pt about safety when getting out of bed Monitor and evaluate fluid intake Scenario #2 Assess for the abrupt cessation of pain Ms. Rails was medicated with hydrocodone 5 mg PO two hours ago and is now complaining of pain (8/10 pain scale). Educate about recovery Provide pt hx of event to team Hypothermia: False -Draw Labs early Imbalance nutrition: True condition Scenario 1 Report current Assessment of bowel Assess insertion site Notify charge RN Contact charge nurse Notify the HCP using SBAR Safety- Love and belonging- Scenario #3 Scenario 3 Her last K was 3.2 mEq/L. Notify lead RN/Dr. Ms. Cumble states that she has not had a BM for three days Determine onset of confusion Establish second Scenario #3 Contact social services Offer assistance in providing more information about treatment options for newly dx AIDS pts. Administer pain meds -Have UAP use therapeutic communication Scenario 4 Perform Wash/glove hands Powerlessness: True Contact provider Chronic confusion: False Psychological Needs - increased Fall Risk - increased Wash hands and don PPE Scenario #5 Contact HCP . Constipation: False Give verbal 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. Impaired mobility, risk for Initiate medication Pain: Increased acuity Risk for injury, Scenario #1 Provide introductory Fall Risk: Increased acuity Health Change: Increased acuity Initiate incident report, Acute pain Bleeding, risk for Begin post-op Use therapeutic 4-Remove the dressings reassess the burns. Contact HCP Pain - increased Encourage positioning Psychological Needs - normal, - Death anxiety BUN -Call RRT and prepare SBAR Scenario #4 This survey aimed to determine the frequency and symptoms of dysmenorrhea, as identified by differen. Place pt. Contact RT Day 2 admission, Thomas Richardson is complaining of severe pain and is now begging you for some relief; states pain scale 10/10 Remove infiltrated IV Ask if the pt understands the procedures scheduled for this AM Reassure pt. Impaired coping: True Educate pt Infection, Scenario #1 Don Johnson Room 306. Reassess VS 4-Place 100% non-rebreather on the patient Assess Mr. Wright's willingness to learn. Assess airway, breathing and circulation Document and accompany, - Educational Needs - increased Cross), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Psychology (David G. Myers; C. Nathan DeWall), Educational Research: Competencies for Analysis and Applications (Gay L. 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Document Psychological Needs - increased, Acute pain Assess toe movement Risk for post trauma syndrome: True Assess food consumption and intake and output Pt. Documents all interactions Guide her back Refer caller Risk for infection Provide comfort Full assessment Scenario #2 Notify Dr. Tell me where you are Provide pt. Allow family Fear: True Document Consult wound care Electrolyte Imbalance True Evaluate understanding Check cranial nerves - Pain - increased Esteem- Scenario #4 Deficient knowledge She was asymptomatic upon arrival. Use therapeutic Fall, risk for: True Preston Wright 10. Pt received furosemide Lasix 20mg, IVP x2, on Claforan Q4, and on sliding scale insulin. Scenario 1 Provide emotional support Obtain doppler pulse Health Change - increased Concepts of Nursing IV 100% (2) Deanna Concept Map Assignment 1. -Wipe down chair with disinfectant Full assessment Mr. Raymond is stabilized w/ RRT. Infection risk Grieving Report Mr. Martinez's Pain - increased Verify call light/ bed safety precautions Disturbed energy field: True Pt. Constipation: False Pain level: Increased acuity Assess VS Educate pt. Fall, Risk for: True Take VS Assess documented pain Mr. Sturgess is uncomfortable w/ experiencing urinary frequency that keeps him from resting - Risk for physical injury Give 1L NS Retrieve cast removal tool Please fill in any remaining missing answers, and let me know if anything is incorrect. Nausea: False Explain that he will Sensorium: Increased acuity, Educational Needs: Increased acuity Scenario #3 call light Disinfect call light Enter the room after taking VS. She was asymptomatic upon arrival. Provide for physical Comfort Notify the HCP of absence of Advanced Directive and the families request to intubate. Fall Risk: Increased acuity Scenario #2 Swift River- Community Health. Verify call light/ bed safety precautions Pain - normal Fall, Risk for: True Begin list of medications and time/dose given. Reassess pt. Do not disturb Stop marking it as incomplete or missing info! Explained HIPPA protocol Introduce hospital liaison, Acute pain Full assessment Inform pt. Evaluate understanding Place pt. Vital assessment Wash/glove hands Promote open Reassess its VS - Fall Risk - increased Health Change: Increased acuity Non-significant past medical history. Three days after d/c, you receive a phone call from Mrs. Stuke's neighbor, who is helping take care of her. - Physical mobility, impaired Love and Belonging- Teach the pt. Assess pt's anxiety Remain w/ pt, Educational Needs: Increased acuity Order a new clear Ensure side rails Ask Hildegard He has bilateral lower lobe atelectasis w/ bronchial vesicular wheezing. Reinforce to the pt. Prepare pt. She is frustrated and overwhelmed with the new appliance not working properly. Social isolation, Scenario #1 Verify call light/ bed safety precautions Ineffective peripheral tissue perfusion: False -Provide emotional support for the patient`s husband. Fall Risk: Increased acuity Impaired gas exchange: True Risk for decreased cardiac output: False Pain Level: Normal acuity 93 terms. Don Johnson, There was a warehouse fire that quickly spread to an adjoining neighborhood. Use therapeutic communication to re-orient and provide reassurance Notify lead nurse Review pain medication order Acute Pain: False Scenario #3 Rape-trauma syndrome: True Begin strict I&O Check foley Infection, Risk for: False She was, asymptomatic upon arrival. Administer anit-pyretics Put on gown Noncompliance, Scenario #1 Chronic sorrow: False Scenario 2 Scenario 5 Reorient pt to setting using therapeutic communication Psychological Needs - normal Pain Level: Increased acuity Contact dietary Therapeutic communication Notify HIPAA Educate pt. Explain the necessary procedure Impaired mobility: True The surgeon added oxycodone 5mg q 4-6 hours prn pain. Take VS LOC: Normal acuity Esteem- Acute Pain: False elisabeth_hamilton. Document on the MAR and education in the chart. Educate pt. -Contact the Provider to tell them the patients pathology report has returned, and Mr. Clinton is anxious to know the findings of his pathology report Assist anesthesia The next day, he tests positive for COVID-19 and his condition has deteriorated as he is now in respiratory distress. -Assess peripheral vision Perform neuro assess Acute Pain: True Document Scenario 3 Administer ordered meds Don gloves Check surgical consent for correct procedure and make sure operative site is marked. Notify HCP Document pt's statements Impaired comfort, risk for joyce workman swift river quizlet. Establish when the cardiac event time began HCP orders digoxin immune fab to be given. Report this activity, Bleeding, risk for Assess VS Explain procedure Ineffective self-health mgmt: False - Drug therapy, Scenario #1 Pt has a hx of COPD, HTN, DM II, and a recent MI. Administer ABX Reassess VS Reassess pt. Have pt. Ask pt. Continue to assist RT in ventilation. Impaired comfort: True Explain that Docetaxel He has been informed that for the next 18 months he should take antithrombotic therapy daily. Mr. Dominec decides he does not want to see the ID MD about his new cough. Monitor for adverse effects Document Remove potential harmful objects Reassure pt. 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. Provide the pt. Fall Risk - normal -Notify the provider after stopping the infusion and legs. Place pt. Employ therapeutic communication: present reality 1-Do not give out any information without consent from the patient 3-Comfort and orient patient to person, place, and time. Scenario #5 Begin fluid and electrolyte Use therapeutic Evaluate pt. Full assessment & family Mary Barkley 3. Altered body image: False Document results - Infection, risk for, Scenario #1 Health Change: Increased acuity Ensure the pt. Offer to contact family for HCP. Scenario 2 Full assessment Administer pain meds Scenario 3 Document procedure Scenario #5 Encourage Mr. Dominec to discuss w/ his partner his best tx options. Ms. Getts is requesting water to drink. Nausea: False Imbalanced nutrition Health Change: Increased acuity ID pt Collect stool 5-Explain discharge orders Assess Ms. Horton's Assess pt's blood glucose Acute Confusion True Neurological - normal 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. Document 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 . Health Change - increased Use therapeutic communication/active listening 10 days later, Mr. Wright's wounds are healing, and you have orders to prepare for d/c w/ home healthcare. Assess pt's LOC Scenario #3 Safety- Assist RT - Knowledge deficit Contact HCP Scenario #2 Prepare and administer appropriate pain medication Teach pt. -Assess radial and apical pulse for 60 seconds LOC: Normal acuity Encourage fluids/fiber/ambulation Assess stress level Address concerns Fall Risk - increased Neurological: Normal acuity Provide morphine Tell the mother that you understand She was asymptomatic upon arrival. Health Change - normal Do not disturb the pt Scenario 3 Sensorium: Normal acuity, Educational Needs: Increased acuity Her temp is 100.8, BP 100/62, P 92, R 21, SpaO2 91. Decreased cardio tissue perfusion: False Scenario #4 IV maintenance fluids with D5 1/2 NS with 20 KCL @ 125ml/hr in left forearm. Take VS Educate pt. Assess understanding through teach back - Risk for malnutrition Scenario 3 Scenario #4 Safety- Scenario 2 Infection, risk for, Scenario #1 Noncompliance: False Restsate or paraphrase Wash and glove hands Health Change - increased Fall risk, Scenario #1 Provide comfort Give an SBAR to hospitalist, Scenario 1 Neurological: Normal acuity Scenario 2 Impaired Skin Integrity, Risk for False 1-Obtain a new IV site Psychological Needs: Normal acuity, Physiological- 1. Educate pt regarding RRT's purpose, Physiological Psychological Needs: Increased acuity, Physiological - Full assessment monitor aPTT Auscultate Take VS now and Q4 hrs Medication abuse Sacrum pressure injury demonstrates underlying bone exposure wound measures 4cm x 6cm x 3cm depth w/ tunneling noted on the rt side. Mrs. Martinez is visiting her husband, who appears to be ignoring any attempts at conversation. Witness daughter Notify HCP Scenario #3 VS: BP 92/58, P 102, R 30 and labored, T 101.3, SaO2 91%. Remain with pt. Elevate extremity Explain to Mr. Wiggins Contact social services
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