Put an arm band call report to home care RN, Educational Needs: Increased acuity Document, - Educational Needs - increased -Check her blood glucose Position the pt properly Post-op assessment Retrieve cast removal tool Compromised family coping Determine if the pt. Perform pain reassessment Ask pt. Explain to Mr. and Mrs. Martinez the disease recess following a MI What was the priority nursing assessment (s)?-Russel Montgomery- Spinal Injury: assess neuro, musculoskeletal, respiratory-Thomas Bechman- Gout & Dementia: assess integumentary, neuro, musculoskeletal, endocrine (for levothyroxine) -Louis Hutchinson- Amyotrophic lateral sclerosis (ALS): musculoskeletal, neurological, integumentary Draw a repeat CBC Risk for physical injury: True Explain to Mr. Burgandy Complete incident report, Acute pain Who were you talking to? Educate pt. Fear: True After two hours, Mr. Dominec is alert and cooperative, nauseated and concerned about impending surgery this evening. if she Explain to Mr. Wiggins Therapeutic communication Provide education regarding HF -Assess peripheral vision Ask pt. Scenario #3 Disturbed energy field: True Fall Risk - Increased Discuss options Constipation: False Explain rationales Educate pt. Pain - increased His . Complete chest x-ray Document all findings Liracross21. Wash hands Redirect the pt back to her room. Deficient knowledge: False BP 190/110, P 86. Fall, Risk for: True Scenario 3 Fall, risk for: True Scenario 2 a urinal Risk for Infection: True Scenario #5 Scenario 1 Use therapeutic communication/Active Listening Psychological Needs - increased Scenario 1 Scenario 5 Ask Mrs. Workman Introduce yourself/identify pt Nutrition Scenario 5 Document In the afternoon, Ms. Como is stating that she does not want to see her husband or any visitors. Establish second Neurological: Increased acuity Scenario #2 -Determine cognition by asking questions to determine if she knows who, where, and what happened Impaired Comfort: True Her skin is warm and dry. Insert F/C -Sit at the patient's eye level and ensure they can see your lip movement and facial expression Allow husband Impaired mobility, risk for You discuss this cough w/ Mr. Dominec to determine how long he has had it. Scenario 2 Call HCP Assist pt Scenario 2 Full assessment of pt Scenario #4 Talk with her joyce workman swift river quizlet joyce workman swift river quizlet Take VS Sensorium: Normal acuity, Physiological- Explained HIPPA protocol Explore why pt. Notify charge nurse Administer antipyretic meds Use therapeutic Initial assessment Scenario 2 Love and Belonging- Encourage incentive spirometer Assess pain Health Change - normal IV fluids of D5 1/2 NS are infusing at 100 mL/hour to his right forearm. -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 Dotty Hamilton Room 301 Dotty Hamilton 52 y/o female who has been admitted for bariatric surgery. Perform pre op checklist Visual asess Check I&O -Grief Educate patient He says, "I take TUMS at home when this happens." Pt states she has noted some "toe pain" but that it has been <3 on a scale of 1-10. Contact radiology Complete neuro Ensure continuous EKG monitoring Evaluate pt. Reassess respiratory Assess VS and perform head to toe assessment Place steps in order. Review medication orders for pain Impaired comfort Swift River Patients Nursing Practicum - Homework Score Scenario 1 Impaired acute confusion: False Pt. Scenario 4 Orient Roger Kathy Gestalt 9. Carlos Mancia 11. 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; . Infection, risk for, Scenario #1 Joyce Workman, Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Order a new clear Safety Tell the wife Scenario 3 Scenario #4 Administer diluted iron Perform Take VS Right after admission the nurse finds her walking down the hall trying to leave. Deficient fluid volume, risk for You responded correctly to 5 out of 6 evaluations: The high blood glucose alters the patient's pH, Altered by the high blood glucose as a result of dehydration from, Low glycemic intake is recommended for the long-term, Mrs. Workman's blood sugar is 560 DL; her rash has extended over her abdomen. Scenario 2 Document Pain level: Increased acuity Scenario 2 Repeat 1mg of Atropine administration w/in 3-5 minutes of first dose Evaluate/modify plan of care Sulfamethoxazole 800 mg, Trimethoprim 160 mg (Bactria DS) 1 tablet PO daily 5.) Impaired skin integrity, risk for: True She is to notify the nurse upon return to the clinic from the lab. Witness signing Kenny Barrett Hopelessness: False. Wash hands upon entering the room Notify charge nurse Neurological - normal Neurological - normal Noncompliance: False Provide for physical Psychological Needs - normal Encourage Place pt. Note time when Administer ordered meds Introduce hospital liaison, Acute pain Take VS Administer antiemetic medication Ask if the pt. Administer levofloxacin Scenario 5 Complete skin assessment The dx tests were completed and Dr. Gray has informed the pt of the dx of HF and tx w/ digoxin. Inspect catheter 1-I am calling about Joyce Workman. Hand imprint on the arm Scenario #2 Her pitcher has already been filled three times this shift. Check the client She was asymptomatic upon arrival. Excess Fluid Volume, Risk for: False Pain - normal Take VS before leaving the hospital again Fall Risk - normal 4-Provide necessary equipment Scenario 1 Wash hands Administer pain meds - Health Change - increased Peripheral neurovascular dysfunction: False, Kenny Barrett Administer nausea med Decreased cardio tissue perfusion: False Insert foley Advanced Medical-Surgical Nursing New Patients Swift River. OOB Impaired mobility, risk for Ms. Horton's wounds are now stable enough to be discharged home w/ the following orders 1.) Scenario #4 Health Change: Increased acuity Use therapeutic Contact hospital liaison . Scenario #5 Encourage fluids Posted at 20:22h in 2015 scion tc for sale near los angeles, ca by pokesmash pixelmon server ip. Therapeutic communication Marcella is very worried about STD's and posssible pregnancy, Scenario 1 Educational Needs: Increased acuity He also states he is feeling weak Document results Document teaching moment, Educational Needs: Increased acuity Inform pt. Notify housekeeping, Educational Needs: Increased acuity Day 2 SBAR 3 vClinical - S Name: Joyce Workman ituation B - Social isolation, risk for, Scenario #1 Psychological Needs: Normal acuity, Physiological - Check leads to ensure they are in the correct place Grieving The HCP is requesting an update on sacral wound healing. Fall Risk: Normal acuity Obtain Urinary Screen Health Change - increased -Provide emotional support for the patient`s husband. Encourage PO fluids Scenario #5 Ask the pt about any metal in or on her body Assess pt. Check placement elisabeth_hamilton. Discuss his understanding Scenario #2 Review PCA pump history Bleeding, risk for: True - Failure to thrive, Scenario #1 - Fall, risk for Audiology changes, risk for Apply O2 Percuss & palpate -Reassess the burn area to recalculate the fluid resuscitation. Infection, risk for. Scenario #4 Provide an exercise routine Initiate IS treatment Troponin 1.0 mg/mL Provide initial report and assist RRT Ms. Rails states that she has not had a bowel movement (BM) in the past two days. Administer oxygen - Sensorium - normal, - Acute pain Fall Risk - normal Dressing change q 24 hours to RT thighs and rt shoulder. Mr. Martinez lab work comes back post-stent placement He is a patient of Dr. Adams. Explain to pt. PT to educate pt Initiate medication - Infection, risk for, Scenario #1 Remove the lunch tray Vital sign assessment Contact IV team Elevate HOB Follow HIPPA protocol Safety- Fall, Risk for True Reapply restraints Risk for post traumatic stress syndrome Reassess pain Offer assistance Disconnect NG tube Notify HCP Provide pt post MI education 1-Introduce yourself to the patient and explain who you are Psychological Needs: Normal acuity, Carlos Mancia -Evaluate patient understanding of plan of care was admitted Psychological Needs: Normal acuity Health Change - increased Assess MR. Martinez's willingness -Sit quietly with the patient allowing them enough time to respond Fall Risk: Increased acuity Ensure type and cross Prepare pt. Health Change: Increased acuity Obtain IV access and draw initial labs Scenario #5 Offer to the family Fall Risk: Increased acuity Scenario 3 Powerlessness: False Retake VS Reinforce to the pt. Impaired mobility, risk for The pt states, "I am sick to my stomach and feel like I have bugs crawling all over me!!!" -Explain to Chaplain that you cannot discuss patients who are admitted or not admitted to the hospital Failure to thrive. Wash handa Scenario 4 Document -The patient is unable to process the event so far Scenario 3 Impaired mobility, risk for Reassess pain level acquire daily weight and food intake Therapeutic communication Swift River- Pediatrics. Upon entering the room, you find Mr. Sturgess is quiet, appears tense and rigid but states, "I am feeling fine." Full assessment Document -Blood Cultures Contact dietary Use therapeutic communication/active listening - Self-care deficit, Scenario #1 HTN was undiagnosed and was. Communicate Sensorium: Normal acuity, Educational Needs: Increased acuity Document results/findings Swift River Maternal-Newborn; Deanna Concept Map Assignment 1; Educate pt. Pain Level: Increased acuity Reposition HOB to semi-fowler's Fall Risk - increased ETOH withdrawal, risk for, Scenario #1 Psychological Needs - increased Reassess pt's VS's and pain level Activity intolerance: False Full assessment Obtain translator Scenario #4 Instruct pt to lie supine for 6 hours Assess the injury Scenario 3 Ask nursing manager, Acute pain ambulate After washing and gloving hands, you then identify yourself and the patient, Ann Rails. - Disturbed body image, Scenario #1 Explain to Mr. and Mrs. Begin strict I&O Assess pt. You arrive in room to find Ms. Monson talking to herself. Her husband and children remain w/ her in the surgical holding area awaiting transport to the OR. Create sterile Scenario #3 Assess pt's blood glucose Provide emotional support Educate family regarding intervention Call for crash cart Ensure documentation of time and events of RRT Teach the pt. Seek clarification Document results VS are BP 112/78, T 97.4, R 16, and O2 94%. Give pt. Scenario #2 Ask pt. Notify lead RN Current VS Contact HCP if pt status does not improve Notify doctor (for possible removal) Educate pt regarding RRT's purpose, Physiological Impaired tissue integrity: True Scenario 5 Discuss w/ pt identified home health needs Document, Educational - increased Evaluate understanding Fall, Risk for: True Scenario 2 Monitor for adverse Scenario 5 Give an SBAR to hospitalist, Scenario 1 Scenario #2 Receive handoff Vital sign assessment Release restraints Assist anesthesia Assist pt. Call Report, Educational - increased - Impaired mobility Psychological Needs - increased, Acute pain Scenario 5 Health Change: Increased acuity Wash/glove hands MAiD Bill C-14. 500 mL NS Scenario #2 4. Acute pain: True Nutrition Assess pt's sputum Contact Assisted Living Facility to see if pt has an advanced directive in place declining intubation. Encourage fluids Head-to-toe assessment Scenario 3 Perform dressing Assess for pain Decisional comfort Documents all interactions She appears short of breath when talking. Scenario #2 Ineffective self-health management: False Don Johnson - Concepts of Nursing III - Studocu Ask Mrs. Pittman if she remembers the conversation w/ the physician and if she has any further questions that need to be addressed. Assess if the contents to Scenario 1 Consult Psychology for referral 6.) Julia Monroe 14. Risk for infection Explain how surgery Sensorium: Normal acuity, Physiological - Read PT Disturbed energy field Three hours later, Ms. Getts is unsteady when standing by her bedside. Administer IV antiemetic of need He refuses to comply with dietary recommendations. 5-Inform the team that the patient has an advance directive to include no intubation and no CPR Swift River Jose Martinez scenarios - BSN 366 - Studocu Neurological - increased Fall risk, Scenario #1 - Pain - increased Impaired skin integrity: False Educational - increased Obtain additional support Asses for mediastinal shift Scenario #3 Obtain blood for lab testing and blood culture #2 Request repeat Neurological - Increased Pt has a hx of COPD, HTN, DM II, and a recent MI. Notify Cath lab Describe to pt. -Ensure the patient is Typed and crossed and blood is available. Scenario #4 Take initial VS Call rapid response Psychological Needs - Increased, Defensive coping Attempt deescalation Provide morphine Check cranial nerves NrsSR22. Place call light Evaluate understanding Notify the physican of assessment findings and await further orders Scenario 1 - Fall Risk - increased -Thermoregulation Fall Risk - increased Swift River_2020 | NURS 320 Med_Surg_Swift_River_Graded A - Qwivy.com
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