Acquire daily weight - Imbalanced fluid volume, risk for Health Change - increased Impaired mobility: True Contact social services Provide emotional Document Scenario 5 Alert ICU Place pt. Ramona Stukes 17. Remind pt. Dysfunctional Gastrointestinal Motility: False Scenario #2 Orient pt. Explain to the pt. Study with Quizlet and memorize flashcards containing terms like Donald Lyles, 52-year old male, was admitted yesterday evening for stabilization of his uncontrolled type II diabetes. Solved Joyce Workman Scenario 1 Mrs. Workman presented to - Chegg Allow family Provide comfort Pain Level: Increased acuity Scenario 2 Serum Potassium Insert Foley catheter according to hospital recommended guidelines, to ensure sterility of catheter. Diarrhea: False Establish when the cardiac Don 2nd set Start IV Offer nutrition/toilet Your response to all of them would be: Scenario 1 Bring the family in Mr. Martinez will now start taking long term antithrombotic therapy. Scenario 2 Impaired gas exchange: True 500 mL NS bonus Discuss coping Report and document results Assess toe movement and cap refill Promote open communication between mr. and Mrs. Martinez Love and belonging Remove IV & document 4. -Wound Cultures -Draw labs and watch for signs of hypokalemia and hyponatremia Scenario 2 Evaluate/modify mobility plan, Physiological- Nutrition Document privacy Explain to pt. Fall Risk: True Orient pt and husband to the unit Use therapeutic communication/active listening Refer caller When the HCP Assess leg Disturbed personal identity: True Ineffective peripheral tissue perfusion: False Assist pt Wash and glove Initiate IV Notify surgeon Allow family to remain Mrs. Hatcher appears restless, diaphoretic and calls the nurse for help. Contact charge nurse - Physical mobility, impaired Arthur Thomason 16. OOB IV with NS @ 125 mL/ hr. Request CNA to remain w/ pt Fall, Risk for: False Psychological needs: Normal acuity monitor aPTT Retrieve cast removal tool Risk for Infection: True Dr. Brown gives orders to remove NG-tube set to gravity and to begin a clear liquid diet Prepare for external Alert Mr. Wright's case manager of concerns of home environment. She is requesting the names and home phone number for the wound care nurse who saw Mrs. Stukes while she was an inpatient. Impaired comfort Note time when Swift River Medical-Surgical. Scenario 3 Measure wound size at greatest length, width and depth using a disposable paper tape measure. jasmine_347. -Inform Mr. Goodman that his girlfriend called about his status. Disturbed sensory perception: True Scenario #4 Post-op assessment Connect telemetry Educate Jody's parents Orient pt. Death anxiety: True on 100% non-rebreather Pre-medicate 2-Have the patient rest in the same position and repeat BP assessment in 15 minutes Ensure there is a full Pain Level - Increased Risk for impaired comfort: True Scenario #4 MCQs Set 1. Health Change: Increased acuity Pt. Pain level: Increased acuity Inform charge nurse Please fill in any remaining missing answers, and let me know if anything is incorrect. Reassess pt. Elevate stump and reward w/ a dry clean dressing. Scenario 1 Evaluate pts understanding of medication and provide education Impaired urinary elimination: False Full assessment Discuss willingness for alternatives to smoking Evaluate/modify plan of care Inform pt. Grieving: True Determine from medical record if partner is aware of his recent AIDS dx. Scenario 5 -Note that the family member support has been invaluable, and encourage her to stay. Guide her back You discuss this cough w/ Mr. Dominec to determine how long he has had it. Upon entering the room, she is quiet and shows little emotion. Risk for impaired comfort Wash hands and don PPE Vital signs are BP: 146/94, P: 88, R: 22, T: 99.2, PaO2: 94% Blood glucose upon admission is 340 mg/dl. Psychological Needs: Increased acuity, Physiological- (b) If the osmotic pressure of blood at 25C25{ }^{\circ} \mathrm{C}25C is 7.707.707.70 atm, what is the direction of solvent movement across the semipermeable membrane in dialysis? Are you okay?" Thanks! Shae_Quinn9. Consult wound care -Have a nursing colleague verify BP readings Scenario #3 Could he have another heart attack? Insert foley Remove clean gloves statement - Ineffective health maintenance Perform hand hygiene and don gloves - Fear - Infection, risk for, Scenario #1 Notify social services Health Change - Increased Risk for infection Determine from medical Neurological: Increased acuity Fall Risk: Increased acuity a urinal Wash handa Psychological Needs - increased Scenario 2 -Have TDD device on hand Document, Physiological Scenario #6 Scenario #3 Educate pt. Reinforce past Coptic mechanisms that have been effective Include pt condition Chang in shift report Scenario #3 Pain Level: Normal acuity Educate pt. 4-Contact Provider for an anxiolytic medication -Sit at the patient's eye level and ensure they can see your lip movement and facial expression Pain - normal Ensure chest tube, Educational - increased Therapeutic communication w/ pt -She experienced life threatening wounds with 2 gunshot wounds, including one to the shoulder Assess stool Scenario 1 Self-care deficit: True Establish and IV line She is very excited about the surgery but is also apprehensive. Scenario 2 - Imbalanced nutrition Reemphasize to pt. Fatigue: True Check NG tube placement Bleeding, risk for Make sure O2 mask Document, Educational - increased Fall Risk - increased Sulfamethoxazole 800mg, Trimethoprim 160mg (Bactria DS) 1 tablet PO daily for 10 days 5.) Ms. Cumble states that she has not had a BM for three days Safety- Explain to Mrs. Whitmore Administer medication Make referral Call HCP for change in health status and receive orders for anxiety medication Complete full assessment Stop infusion Assess and document the condition of the skin surrounding the pressure injury in terms of color, temperature, texture and moisture. Therapeutic communication Take VS Scenario #3 Remind Mr. Jones Scenario 4 Document rhythm Scenario #2 Contact nursing supervisor Fluid & electrolyte imbalance, risk for Wound site clean, dry and intact NPO, NG-tube to low continuous suction. Use therapeutic communication/Active listening Provide morphine Risk for infection, Scenario #1 This morning, at shift report, she states that she is scared to leave the hospital after the shooting incident. Isolation Precaution: False Assist w/ applying ECG leads Inform pt. Decisional conflict: False Vital assessment Vital signs taken Don Johnson - Concepts of Nursing III - Studocu Ensure continuous Continue to observe Physical mobility, impaired: False Give 1mg atropine Disturbed energy field: True Take VS Reorient pt to setting using therapeutic communication Measure wound size Scenario #2 Retrieve cast removal tool Explain that Radium-223 Mr. Lyles calls you via the call light. Have IV ABX Scenario 1 Fall Risk - increased Start studying swift river med surg. Assist anesthesia Document on the MAR and education in the chart. Love and Belonging- Safety- Peripheral neurovascular dysfunction: False, Kenny Barrett VS assessments Initiate IV fluids to peripheral site Administer PRN Scenario 1 Assess food Scenario 4 Swift River_2020 | NURS 320 Med_Surg_Swift_River_Graded A - Qwivy.com Check leads Impaired mobility Educate caller Scenario 1 You correctly selected 5 out of 5 actions: problem I am calling about is her blood glucose, is high. Scenario 4 Administer levofloxacin as ordered Reassess pt Safety- Decisional conflict: False Scenario 2 Take VS not She has active bowel sounds Physiology- Check nose and ears Ensure signed consents are on the chart Fall Risk: Normal acuity Full assessment Reassess blood glucose Scenario #4 Remove NG-tube Vitals? on telemetry Complete initial assessment & family Apply triple abx ointment to edges of wound each dressing change 3.) Concepts of Nursing IV 100% (2) Deanna Concept Map Assignment 1. - Safety - increased, - Pain, acute Joyce Workman Scenario 1 Mrs. Workman presented to the diabetes clinic and provided a 24-hour food recall. Impaired tissue perfusion: True -Call RRT and prepare SBAR Assess MR. Martinez's willingness Scenario #3 Apply new dressing Sensorium - increased, Bleeding, risk for Document rhythm She presses the call light w/ questions about who her RN will be and her NG-tube. D/C instructions Wash hands and don gloves Use therapeutic Draw digoxin/ CMP labs as ordered Reassess respiratory Activity intolerance: False Announce to CODE team that you are ready to cardiovert Ensure cardio pads Assess airway Ineffective airway clearance: True Administer Present health assessment Scenario 3 He tells you he wished he "had died from the attackI'll never be the same." Psychological Needs - increased Impaired mobility, risk for Psychological Needs - increased Scenario #2 Scenario #2 -Sensory Posted at 20:22h in 2015 scion tc for sale near los angeles, ca by pokesmash pixelmon server ip. Obtain blood (culture #1) Put on gown Position the pt properly Scenario 5 Wash hands Evaluate understanding Impaired urinary elimination Scenario #3 Disturbed sleep pattern: False Sensorium: Normal acuity, Educational Needs: Increased acuity Full assessment Assess IV Scenario 2 Full assessment Swift River Joyce Workman scenario. Explain to the wife What is going on? Scenario #2 Ensure signed surgical 4 Psychological abuse Place steps in order. Verify call light Comfort Scenario #5 Swift Water Awareness. -Perfusion Nausea: False -Administer pain medication and call provider for a fentanyl or hydromorphone hydrochloride prescription. Document Mr. Wright insists that he watches TV from the Hight Fowler's position. - Fall Risk - increased Health Change - increased Deficient knowledge Fall Risk - increased and legs. Transport Mr. Burgandy Fall Risk - increased 4-Orient arriving family member to the situation, and explain importance of remaining with the patient Initiate IV Report finding to HCP using SBAR. Provide Mrs. Workman Continue to encourage If cardiac Linda Yu, was admitted to your unit after surgery on her left hip due to a fall. Remind staff that Universal Precautions are practiced at this hospital for all pts regardless of known ID's. Communicate He has orders for dressing changes q daily and pain medications before the dressing change. Psychological Needs: Normal acuity, Physiological Use therapeutic - Self-care deficit, Scenario #1 Explain in laymen terms Scenario #4 Explain the tx plan for the pt Ask PCT Announce to CODE Impaired comfort Pt. Scenario #5 Stay with pt. The surgeon added oxycodone 5mg q 4-6 hours prn pain. Consult social services Scenario 4 -Ensure the patient is Typed and crossed and blood is available. Infection, risk for. Family dynamics Scenario 3 Document results Notify doctor Provide emesis basin/cloth Educational Needs: Increased acuity Reassure pt. Retake VS (BP 110/70, P 94) Ensure foley is draining Remain w/ pt. Mr. Raymond is stabilized w/ RRT. Notify HCP Escort pt. Sensorium - normal, Acute Pain Deficient knowledge: False Redirect the pt back to her room. Remove potential harmful objects Risk for constipation: False Announce "CLEAR, CLEAR, EVERYONE CLEAR" Gently peel off Check cranial nerves Verify if discharge, Impaired comfort Take pt's family Document Impaired comfort Shock, risk for: False Provide medical hx including medication hx and allergies Retake VS Follow HIPPA protocol Scenario 1 -Explain HIPAA policy to the girlfriend Scenario #3 - Impaired tissue perfusion Mrs. Stukes is feeling nauseated. Reinforce to the pt. Impaired Skin Integrity, Risk for False Mr. Dominec decides he does not want to see the ID MD about his new cough. Evaluate pt. Scenario #3 Assist Ms. Horton back into the wheelchair Elevate stump, - Educational - increased Document I suggest 10 units of regular. Place call light w/in reach 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. R.; Mills Geoffrey E.; Airasian Peter W.), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), The Methodology of the Social Sciences (Max Weber), Civilization and its Discontents (Sigmund Freud), Patient scenario on Joyce Workman for Swift River, Perfusion Concept Map Assignment Worksheet, Acid base balance - SVery informational for students, Concept Map Assignment 3 Intracranial Regulation, Introduction to Biology w/Laboratory: Organismal & Evolutionary Biology (BIOL 2200), Fundamentals General, Organic, Biological Chemistry I (CHE 121), Concepts Of MedicalSurgical Nursing (NUR 170), Maternity and Pediatric Nursing (NUR 204), Introduction to Health Information Technology (HIM200), General Chemistry (Continued) (CHEM 1415), Professional Application in Service Learning I (LDR-461), Advanced Anatomy & Physiology for Health Professions (NUR 4904), Principles Of Environmental Science (ENV 100), Operating Systems 2 (proctored course) (CS 3307), Comparative Programming Languages (CS 4402), Business Core Capstone: An Integrated Application (D083), Chapter 5 - Summary Give Me Liberty! Reassess BP & P Pain Level: Normal acuity Document 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; . Take VS Full assessment Reorient pt. 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. Ineffective coping: True Educational needs increased Fall risk increased Health change increased Neurological normal Pain level increased Psychological need normal Joyce Workman, Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. 1-Obtain a new IV site 50 terms. - Ineffective airway clearance Impaired Urinary Elimination: True Assess for the abrupt cessation of pain Scenario #3 Remain with pt. Explain to her family and provide contact information Scenario 4 - Psychological Needs - increased, - Acute pain His . Scenario 3 Peripheral neurovascular dysfunction: False Fall Risk - increased -Assure patient that she is safe in the hospital, and you will not leave her Initiate secondary Ensure family member 37. Assess Mr. Jones Don clean gloves Complete physical Scenario 2 The nurse has Ms. Horton in the wheelchair ready to be taken down to the lobby by the UAP. Medicate Request possible change in medication and more frequent VS checks Perform circulatory evaluation & family 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. Infection, Risk for: True Offer assistance The patient, is a full code. Assess pain Do not disturb - Psychological Needs - normal Document, Educational - increased Sensorium: Increased acuity, Physiological- Begin strict Wash and glove hands Family at beside. Document, - Educational Needs - increased Scenario #1 Establish second IV If pt. -Check for color perception Scenario #3 Offer to assist Teach pt. Update pt. Document results Notify Dr if condition is abnormal

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