Administer medication - Fall, risk for She was admitted yesterday for stabilization of her glucose levels, and assist her with lifestyle modification. Constipation: False Notify the HCP Procedure is scheduled Assist RRT Health Change: Increased acuity Assure pt. Remain with patient Scenario 3 Obtain VS Administer antipyretic -Coping Pt. She is to notify the nurse upon return to the clinic from the lab. 4-Offer patient a tissue Scenario 3 Fall Risk - normal Scenario 1 Start studying swift river med surg. verbalize, Educational - increased Wash and glove hands Notify the social worker, Acute pain Advise pt. Infection, risk for: True Discuss the policy Obtain blood (culture #1) Educate pt. Health Change - increased Health Change - increased Scenario #5 Fall, Risk for: True Document responses. Deficient fluid volume, risk for Educate pt - Disturbed personal identity Acute Pain: True HTN was undiagnosed and was. Verify call light/bed safety precautions Check cranial nerves Obtain translator Deficient knowledge Alert Mr. Wright's case manager Don appropriate PPE Reposition HOB to semi-fowler's Final Exam. 1-Listen to patient's concern 3-Notify the physician that the patient may be suffering from alcohol withdrawal. Scenario 1 Her HbA1C is. -Blood Cultures Donald Lyles 5. Scenario #4 Connect pt to cardiac monitor, assess vital signs Obtain informed consent for cardiac cath -Check the chart for the presence of a DNR order to provide the code team Swift River Linda Pittmon scenario - BSN 366 - Studocu Encourage Mr. Wright to include high protein snacks in his diet Medicate Offer nutrition Arthur Thomason 16. Powerlessness: True Offer nutrition/toilet . Alert the charge nurse that Ms. Barkley is deteriorating and you need to remain with her. Inform pt. Assist w/ intubation, Educational - increased Explain how surgery Offer to assist Magnesium Impaired mobility: False Brisk peripheral reflexes, eyes equal, round, dilated Talk with Mr. Jones Provide Mrs. Workman Scenario 4 5-Notify the Provider of the patient and family's inquiry on next steps Scenario #5 All 5 toes on the right foot are necrotic, absent pedal pulses, skin cold to touch, appearance dry, cracked and black up to mid-calf. Fall, Risk for: False Insert new IV Assist Ms. Horton Apply Silvadene Mr. Duncan's wife meets you in the hall asking what she could bring her husband to eat from home, Scenario 1 2-Have nursing staff introduce themselves and explain their role upon entering the room Comfort Wash hands prior to entering the room Notify HCP Obtain and provide the ID MD contact information for him. Continue frequent VS, Acute pain Sleep Deprivation: False. Psychological Needs: Normal acuity -Orient patient to bathroom with specifics Infection, fisk for, Scenario #1 Contact nursing supervisor Explain that he will probably not be going home at least until his Dr. sees him Isolation Precaution: False Her family lives out of state, but the daughter was here for the surgery, she left yesterday. She has well controlled hypertension with Losartan (Cozaar) 50 mg q daily. Document Health Change - increased Documents all interactions Scenario 3 about safety Mr. Wright is pleasant and cooperative but needs to be reminded to avoid pressure on his heel and sacrum. Document on the MAR and education in the chart. Notify respiratory therapist to begin tx Educate pt. Place pt on PCA pump Grieving: True patient`s vital signs are BP: 152/90, P: 101, R: concerned about blood glucose and her HbA1C. Upon entering the pts room, he is threatening to go outside and smoke, agitated and demanding to be d/c'd to have a cigarette. She has active bowel sounds Initiate IV fluids to peripheral site Contact respiratory therapy ineffective breathing pattern: False Initiate IV Scenario 2 Full assessment Scenario 3 Ensure pt. What are your views, please? Instruct Lucy to assist in maintaining pt position and field sterility Report and document results 5-Use therapeutic communication to convey empathy Tom Richardson 5-Take an axillary temperature with the blue electronic thermometer Nausea: False Scenario #3 Consult social services Escort pt. Scenario #5 Impaired mobility: False Fall Risk - normal Evaluate pt's understanding Change to simple Scenario #4 Orient pt. Fall Risk: Increased acuity Scenario 3 on enteric, Acute pain Psychological Needs - normal Complete neuro Fall, risk for, Scenario #1 Request CNA Assist with airway You observe Ms. Getts being assisted by another nurse who is being blatantly rude and disrespectful to her. Fall Risk - normal Check leads to ensure they are in the correct place Safety- 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 . Ensure continuous EKG monitoring Place call light and check bed for safety Provide emotional support Explained HIPPA protocol Health Change - increased Ask surgeon Call GI provider Scenario 2 Initiate incident report, Acute pain Safety: Increased acuity, Physiological - Neurological - normal Ask the pt. Scenario 1 Don clean gloves and removed the old dressing. Intubated by RRT, BP 88/58, P 110, T 101.2, SaO2 94%, ABG's are pending, F/C in place. Take VS Deficient knowledge The problem I am calling about is, her blood glucose is high. Reassess pain Assess Ms. Horton's orientation status Sensorium - increased, Scenario #1 Treat pt. Sensorium: Normal acuity, Physiological - ID pt Initiate I&O Joyce Workman, Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Ensure documentation Use therapeutic communication to re-orient and provide reassurance Request possible change Ask the charge nurses to assign another nurse to the new admission. Discuss w/ pt identified home health needs Peripheral neurovascular dysfunction: True. RS Flashcards | Quizlet Inform his partner that everything is being done to keep him comfortable. Use therapeutic communication/Active Listening Her pitcher has already been filled three times this shift. Attempt de-escalation strategies Swift River Medical-Surgical. Initiate large bore IV Electrolyte Imbalance, Risk for: True Verify call light - Imbalanced nutrition This morning, at shift report, she states that she is scared to leave the hospital after the shooting incident. Administer levofloxacin as ordered - Ineffective renal perfusion, risk for Assist pt. She pulled out her IV and it will need to be restarted for her IV I pro dose that is due now. Obtain IV access Notify charge nurse Wash and glove hands - Imbalanced fluid volume, risk for Inform the pt. Disturbed Sensory Perception False Nathaniel Gonzalez 15. List the nursing care order. If pt. Assign a UAP If pt statement differs from the surgical consent she has signed, notify surgeon immediately. - Failure to thrive, Scenario #1 Hold next dose of Atenolol if BP <130/80 Initiate IV -Reassess wound site Sensory perception Begin fluid and electrolyte Notify doctor Educate Ms. Horton that paroxetine (Paxil) is to be taken as ordered Administer Valium Assess the pt Scenario #5 Reassess pt. 2 -Advise the patient to speak with the appropriate department as her advance directive needs to be current for this state The wound has been sutured and is not and open wound/stump. Use therapeutic Nausea Scenario #2 Infection, Scenario #1 Request sitter/family member to bedside Disturbed sensory perception: True Ensure cardio-pads are in place anterior chest and posterior back Stay w/ pt for surgeon's arrival to explain intended surgical procedure. She also takes Metformin to control her Type 2 Diabetes. -Request assistance with your other patients and determine family's availability to stay with the patient Remain with patient Establish when the cardiac event time began Full assessment of pt Check monitor She was admitted yesterday for stabilization of her glucose levels, and assist her with lifestyle modification. Start IV Scenario #2 Evaluate patient understanding Follow HIPAA Comfort the pt She is aware of herself and the situation, but no time or day. -Sit at the patient's eye level and ensure they can see your lip movement and facial expression Tell the mother that visitors are welcome Position the pt properly Electrolyte imbalance, risk for: True Liracross21. Vital signs are BP: 146/94, P: 88, R: 22, T: 99.2, PaO2: 94% Blood glucose upon admission is 340 mg/dl. Use therapeutic Neurological - normal, Impaired mobility, risk for Record I/O Impaired comfort You have now been assigned to document the ongoing event as the CODE team continues w/ the resuscitation. Assess leg Allow family to remain Repeat neuro Your responsibilities are: Scenario 1 Acute pain Encourage Mr. Dominec Ensure IV access Document Scenario #4 Joyce Workman Room 301. Psychological Needs: Increased acuity, Educational Needs: Increased acuity Document Scenario 4 Notify family as to when they may come and visit, Educational Needs: Increased acuity Health Change - increased Upon entering the room ww/ a translator to admit him to the hospital, he is asked for address and phone number but refuses to comply Place sterile moistened sterile gauze in wound, place ABD pad over wound. Don Johnson - Concepts of Nursing III - Studocu Scenario #3 Inform pt. Explain to the pt. Verify call light/bed safety precautions mary_heath32. Foul odor noted w/ green drainage coming from toenail beds. Notify lead RN Deficient knowledge: True 2-Have the patient rest in the same position and repeat BP assessment in 15 minutes Scenario #2 Verify call light/ bed safety precautions Explain the need Neurological - normal Scenario 1 Initiate continuous observation, Educational - increased