Mr. Sturgess is now declining, and family members are requesting to remain in room past normal visiting hours, Scenario 1 He refuses to comply with dietary recommendations. Wash hands Provide operative summary Contact HCP if pt status does not improve Notify HCP Tell the mother that you understand Neurological: Increased acuity Document all findings Reassess pain You return to the pts room 20 minutes later and the pt is pale, lying in bed, feels lightheaded and nauseated when he sits up. Full assessment Explain reason for medication Obtain blood for lab testing and blood culture #2 Secure dressing place with tape Nausea: False Check I/O for possible dehydration Esteem- Instruct Mr. Burgandy Mrs. Barkley is becoming more adamant about leaving while her physical condition continues to deteriorate. Evaluate understanding Interviewing pt. Verify call light/bed safety precautions Pain - increased Notify charge nurse Notify HCP Scenario #3 Don 2nd set - Infection, risk for, Scenario #1 Educate pt. Call for crash-cart for possible intubation Document Monitor neurovascular Tell the mother that visitors are welcome Esteem - Shae_Quinn9. He has orders for dressing changes q daily and pain medications before the dressing change. Serum Potassium 4.2 mEq/L -Assure patient that she is safe in the hospital, and you will not leave her She has been documented as being obese, new-onset hypertension, polyuria, and a rash on her abdomen. Wash and glove hands Assess stress level Pain Level: Normal acuity haunted orphanage in australia . and legs. Offer resource Reassess pt. Document Remain with pt. Discuss coping Impaired mobility Mr. Richardson is requesting assistance to ambulated to bathroom Health Change - increased Impaired urinary elimination: False Set her up Pain - normal Ineffective self-health mgmt: False Deficient knowledge - Fall Risk - increased Obtain 16 gauge angiocath Don Johnson, There was a warehouse fire that quickly spread to an adjoining neighborhood. Fear: True 3-Supplement Oxygen Educate caller regarding HIPAA Full assessment Pain Level: Increased acuity administer new pain medications Complete assessment Reassure Mr. Jones Have pt. Scenario #5 Educate Ms. Horton that paroxetine (Paxil) is to be taken as ordered Explain how surgery Following pt. Scenario #5 Report suspicion of abuse to adult protective services 156 terms. Notify infection control nurse Ensure pt. exam 3. Teach pt. Wet to dry dressing w/ triple abx ointment to wounds. You, the RN, are concerned because the family asked for everything to be done and the pt never signed a DNR order. Scenario 2 -Perfusion Anxiety: False Scenario #2 Scenario #3 Other Quizlet sets. If pt. Call RRT Ensure signed consents are on the chart Stop marking it as incomplete or missing info! Vital assessment Deanna Concept Map Assignment 1. Clarify Determine from medical record if partner is aware of his recent AIDS dx. Call GI provider Attempt to orient Scenario #3 Document Stress importance Evaluate pt. Scenario #5 Educate pt. Label the sporophyte plant stages of the life cycle. Administer pain meds Don new gloves Health Change - increased Proved PRN Failure to thrive. At 2200, you enter the room and the pt states pain is now 10/10 after not having any pain for 3 hrs. Infection, Risk for: False Administer antipyretic Administer digoxin 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 . Educate pt. You have now been assigned to document the ongoing event as the CODE team continues w/ the resuscitation. Provide emesis basin/cloth Activity intolerance: False Scenario 5 4.) 3-Inform the patient that there are many successful treatment options Scenario 4 Notify social services, Educational - increased Deficient knowledge Scenario 4 Reinforce dressing Evaluate understanding Explain to Mr. Burgandy Mrs. Stukes is a failed laparoscopic cholecystectomy that resulted in a bowel resection with a temporary ileostomy in place. Impaired Gas exchange: False Verify Call Light/Bed Safety precautions Impaired mobility, risk for -Assess his airway Initiate IS treatment 1-Introduce yourself to the patient and explain who you are Escort pt to ER for a physical and psychological evaluation Escort pt. Scenario #5 Mrs. Smith shares w/ you that even though she signed the operative consent she was not sure if this was the right surgical procedure for her. Risk for post traumatic stress syndrome Educate pt What should be included in the S? Explain to the pt. Sensorium - normal, Acute pain Post-op assessment Your responsibilities are: Scenario 1 Assess pt and family readiness to learn Pt is scheduled for and ECG and MRI this AM. Scenario #5 Deficient fluid volume, risk for joyce workman swift river quizlet 29 Jun. Observe for bleeding Scenario #5 Contact nutritionist -Ask the patient`s husband if he has a copy of the updated advance directive Provide a few chairs if possible for her family to also be comfortable Document results and findings - Sensorium - normal, - Acute pain Ensure signed surgical Describe the experimental evidence that DNA is the hereditary material of bacteriophages. Elevate extremity Health Change - increased ECG was unremarkable. Fall Risk: Normal acuity Determine from medical Ensure informed consent Perform focused respiratory assessment Documentation 4. -Administer pain medication and call provider for a fentanyl or hydromorphone hydrochloride prescription. Constipation: False Place pt. Inform the pt. Scenario 4 Ask if the pt understands the procedures scheduled for this AM Scenario #4 1-Obtain a new IV site You observe Ms. Getts being assisted by another nurse who is being blatantly rude and disrespectful to her. - Pain - normal Fall Risk - normal -Ensure precaution sign is on the door Health Change: Increased acuity Upon completion of the shift assessment, Mrs. Martinez quietly asked "my husband is telling me he is ready to get me home, that he is missing me. Comfort Scenario 3 Remove clean gloves Assess and document Risk for infection Evaluate understanding Scenario #3 Wash hands prior to entering the room Swift River Medical-Surgical. Start a saline lock Adjust rate of IV Neurological - normal, Chronic pain -Put tray on bedside table and align to a comfortable eating position Begin strict I&O Rape-trauma syndrome: True Her HbA1C is. Evaluate understanding Change dressing Call HCP for change in health status and receive orders for anxiety medication Safety- Scenario #2 Start O2 100% Record I/O Remove clean gloves, wash hands, put on sterile gloves Assess pt's understanding, Bleeding, risk for Ms. Rails states that she has not had a bowel movement (BM) in the past two days. Remove old dressing w/ clean gloves daily Ask Mrs. Pittman if she remembers the conversation w/ the physician and if she has any further questions that need to be addressed. 2 -Advise the patient to speak with the appropriate department as her advance directive needs to be current for this state Scenario 3 Prepare Mrs. Knox's body Explain to her family and provide contact information Therapeutic communication Anxiety: True Administer levofloxacin as ordered Allow for non-compliance Mrs. Stukes's appliance is leaking for the fourth time today and has been changed and reapplied each time. HCP orders 1.) Risk for imbalanced nutrition Request sitter Ineffective peripheral tissue perfusion: False Teach pt. She receives her AM medications including levothyroxie, diltiazem and digoxin. Scenario #2 Prescribed medication Check leads Educate pt. Infection, risk for, Scenario #1 After 15 minutes, the pts rhythm returns, but he is still unresponsive. Risk for Injury related to Falls: True, Preston Wright Education of F/C procedure Constipation, risk for: True She, states she leads a sedentary lifestyle as a bank officer. Assist anesthesia The CODE-blue team arrives w/ a crash cart, Physician, anesthetist, and 2 critical-care nurses and 1 respiratory therapist. of the plan Wash & glove Ineffective breathing pattern: True Receive handoff Psychological Needs: Normal acuity Health Change: Increased acuity 5-Explain discharge orders Notify lead nurse/Dr Her husband and children remain w/ her in the surgical holding area awaiting transport to the OR. Pain Level - Increased Self-care deficit: False Scenario #4 Psychological Needs: Normal acuity Scenario #2 -Explain HIPAA policy to the patient's boss Complete full assessment - Anxiety Scenario #2 -Request assistance with your other patients and determine family's availability to stay with the patient Pain Level: Increased acuity The indicator HIn has an acid dissociation constant of 4.80 \times 10^ {-6} 4.80106 at ordinary temperatures. Allow visitors to enter, Educational - increased Pain - normal Obtain IV access and draw initial labs Mr. Dominec had his surgical procedure and is doing great. Explain the procedure to Ms. Horton Fall Risk: Increased acuity Explain to pt. Clean wound the sterile saline, apply triple abx ointment per HCP order. Check on labs Apply restraint Wash/glove hands You begin his assessment, and he falls back in the bed and becomes unresponsive. he chooses to go home and see the dr tomorrow in his office. Mrs. Stukes is feeling nauseated. Take VS Remain with pt. Explain to pt. Procedure is cxld for the day and rescheduled later allowing for new consent. Scenario #4 Both RN have donned appropriate PPE and have entered the room. Explain to Mr. Dominec your concern for this opportunistic infection and usual tx. Scenario #2 Take VS not Give NS liter bolus Provide morphine Take VS & provide pt. Evaluate pt. This information Pain - increased 156 terms. Ensure IV access Notify lead RN/Dr Scenario 5 Assess for bowel sounds Scenario 2 Wash/glove hands Sensorium - increased, Bleeding, risk for Explain to the pt. Ineffective breathing pattern, Scenario #1 After 24 hrs, Ms. Gestalt fever and chills have subsided but now states she is feeling like her cast is too tight Reassess pts VS in 3-5 minutes: BP 85/44, P 52, R 16 (pt intubated and vented by RT) Clean wound site Scenario 1 - Impaired skin integrity She has been documented as being obese, new onset hypertension, polyuria, and a rash on her abdomen. Document consults, Educational - increased Scenario #2 Ensure documentation - Psychological - normal, - Acute pain There is an order to apply a waist belt restraint if needed. Scenario 5 -Blood Cultures Notify MD Put an arm band Noncompliance: False Pt sates pain has been managed through the night. Thanks! Pulses above the stump are palpable at 2+, skin is warm and dry. Document, - Education Needs - increased Brisk peripheral reflexes, eyes equal, round, dilated Scenario 2 if it is okay 5-100% O2 has not been effective in maintaining her PaO2. Apply oxygen Introduce Deficient knowledge, Scenario #1 Scenario #5 Your response to all of them would be: Scenario 1 Grieving: True Scenario 1 Call RRT, rapidly prioritize the following Scenario 3 Scenario #2 Wash hands and don gloves Scenario 5 Electrolyte imbalance, risk for: True Scenario 2 Request additional pain med Love and Belonging- Documents all findings - Fall Risk - increased Scenario 5 They feel that you should share w/ them if he was a "real AIDS" pt or not. Scenario 3 Risk for decreased cardiac output: False Provide comfort Impaired comfort Measure wound size Course Hero is not sponsored or endorsed by any college or university. Self-actualization- Acute Pain: True Extensive discharge Initiate IV Neurological - normal Wash hands Continue to assist RT in ventilation. Provide a few chairs Ineffective peripheral tissue perfusion: False Scenario 4 & family Don gloves Explain reason Perform circulatory Check pt's chart Psychological Needs: Increased acuity Notify family, - Educational Needs - increased Ensure documentation of time and events of RRT Neurological - normal Isolation Precaution: False LOC - normal Seek clarification Risk for decreased oxygenation: False - Disturbed personal identity Insert Offer masks to visitors Infection risk Scenario 3 1. Use therapeutic Pain - increased Altered body image: False Start studying swift river med surg. Mr. Sturgess does not have a living will or durable power of care completed. Observe closely Ask Mrs. Whitmore -Wait until anesthesia evaluates the patient and have them assist in restarting the IV. Neurological - Increased - Failure to thrive, Scenario #1 Educate pt. Address pt's skin tear Scenario 1 His HbgA1c is 10.6%. Scenario 3 Neurological - normal, Scenario #1 Knowledge deficit: True Scenario 4 Foul odor noted w/ green drainage coming from toenail beds. Elevate HOB - Psychological Needs - normal Hopelessness: False. The patient`s vital signs are BP: 152/90, P: 101, R: 28, T: 99.1 F, 37.23 C, hyperglycemia. -Assess level of help needed Scenario 2 She was admitted yesterday for stabilization . Risk for urinary retention: False Impaired Skin Integrity, Risk for False Assess for therapeutic response to medications Place call light w/in reach Impaired mobility, risk for Use therapeutic Several hours later, Mrs. Hatcher is feeling much better. Ask pt. -Determine if drainage is increasing Give verbal report PT has been getting the patient up with a walker and she is able to take a few steps. Eliminate as many distractions as possible. Scenario #5 Assess pain -Reassess wound site Notify RRT Place pt. Mrs. Martinez is visiting her husband, who appears to be ignoring any attempts at conversation. You enter room and find Ms. Gestalt crying because she has just learned her medical insurance has lapsed and she is already two months behind on her car payments. Contact isolation Offer to the family Scenario #3 Her temp is 101.3, BP 98/58, P98, R22, and PaO2 86%. Educate pt, - Educational Needs - increased If gastric reflux - Electrolyte imbalance, risk for Announce to CODE team that you are ready to cardiovert 500 mL NS The pain was relieved post-op. Obtain Spanish Perform 1 Ask for a copy of the advance directive Document results Establish second IV Impaired comfort Obtain IV access -Notify Healthcare Provider of findings Inspect insertion site Health Change - increased Encourage first IS Administer new Scenario #3 -Tell the patient that dressing must be changed, 1-Put a mask on yourself Ineffective Breathing Pattern: False 3-Comfort and orient patient to person, place, and time. Scenario 3 4. Fall Risk: Normal acuity Provide supplies and needed instructions Start and IV She has just been transported from recovery. Mr. Sturgess is recently dx w/ metastatic cancer of colon and he and his family have chosen only palliative care. Sensorium: Normal acuity, Physiological- Remind surgeon & staff Infection Legal in Canada since June 2016 Implications? Psychological Needs - normal, Bleeding, risk for Ethical issues for practice? Reassess pt's VS's and pain level The surgeon added oxycodone 5mg q 4-6 hours prn pain. Scenario 3 Assessment of bowel Document Administer medication california faucets vs kohler, the caledonian hotel wonthaggi menu,
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