Use teach back Use therapeutic Remove the lunch tray Prescribed medication Place steps in order. Perform pre op checklist Swift River Joyce Workman scenario. Skin integrity at risk Notify lead RN/Dr Complete full assessment Obtain blood (culture #1) Monitor and evaluate Continue to provide Deficient Fluid Volume: True Scenario #2 Prepare and administer appropriate pain medication Assess Mr. Jones Elevate extremity Scenario #5 1-I am calling about Joyce Workman. Eliminate as many Assess for injury Prepare and administer 1-Obtain a new IV site Obtain burn sheets Scenario #5 Scenario #4 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. Scenario 4 Encourage fluids Evaluate understanding Verify call light 4-Place 100% non-rebreather on the patient Rape-trauma syndrome Risk for Infection: True Tissue integrity 4-Offer patient a tissue Scenario 1 Legal in Canada since June 2016 Implications? Check surgical consent Contact charge nurse Scenario 4 Place sterile moistened sterile gauze in wound, place ABD pad over wound. Promote open communication between mr. and Mrs. Martinez D/C instructions She is aware of herself and the situation, but no time or day. Fall Risk - increased Document process Administer IV ABX Call rapid response - Fall Risk - increased Update pt. - Fall Risk - increased Neurological - normal, Bleeding, risk for MAiD Bill C-14. Use therapeutic communication/active listening Review plan Contact HCP Notify lead RN Scenario #3 was admitted Verified answer. Sensorium - normal, Impaired coping 4-Contact Provider for an anxiolytic medication Notify doctor (for possible removal) Assess understanding Psychological Needs - increased, Acute pain Fall Risk - increased Administer ABX Fall Risk: Increased acuity Assess airway, breathing and circulation Ms. Horton's wounds are now stable enough to be discharged home w/ the following orders 1.) Infection, risk for, Scenario#1 Evaluate understanding This survey aimed to determine the frequency and symptoms of dysmenorrhea, as identified by differen. - Failure to thrive, Scenario #1 Request the uncle come Assist pt. Current VS BP 110/70, P 94, pt is pale, dizzy and nauseated. . 5-Take an axillary temperature with the blue electronic thermometer Ms. Getts is now complaining of sudden sharp, substernal chest pain, very short of breath and is profusely diaphoretic. Assist anesthesia Wash hands Assess and document Check VS Notify Dr if condition is abnormal Notify the charge Upon entering the room, you find Ms. Rails sleeping. Scenario 2 Wash handa - Hopelessness Risk for post traumatic stress syndrome Assist RT Take VS Insert - Psychological Needs - normal Contact hospital liaison Vital assessment 7. Comfort the pt Health Change: Increased acuity Retrieve cast removal tool Inform admitting physician Use therapeutic communication/active listening Notify charge nurse Review with Mrs. Workman Sensorium: Normal acuity, Physiological- joyce workman swift river quizlet 29 Jun. Kathy Gestalt 9. Obtain a sitter/UAP Scenario #3 Provide therapeutic Encourage Reassess pts VS in 3-5 minutes: BP 85/44, P 52, R 16 (pt intubated and vented by RT) Evaluate pt's understanding HTN was undiagnosed and was. The sister of Mr. Mancia calls from home to speak w/ you. He is anxious that he will forget to take it or take the wrong dose. Imbalanced Nutrition: False Scenario 5 Scenario #4 IV fluids of D5 1/2 NS are infusing at 100 mL/hour to his right forearm. Notify lead RN/Dr. Scenario #3 Assess VS Orient pt. Provide report to ER RN, Educational Needs: Increased acuity Pt received furosemide Lasix 20mg, IVP x2, on Claforan Q4, and on sliding scale insulin. Establish responsiveness Both RN have donned appropriate PPE and have entered the room. -Ensure pathway is clear Notify the HCP of absence of Advanced Directive and the families request to intubate. Wash hands Report and document results Document all findings Two housekeepers, who were refusing to clean the room, are in the break room. Explain s/sx of wound infection. Infection, risk for Medicate Dressing change q 24 hours to RT thighs and rt shoulder. 10 terms. Notify charge nurse -Explain HIPAA policy to the patient's boss jessdevan. Complete full assessment ", Scenario 1 Scenario #5 Check the blood Bleeding, risk for: True -Inform the patient that we cannot honor her current advance directive Physiology- Assign a UAP Fall Risk - increased - Fall, risk for Remain with patient Scenario #5 Sensory perception -Put tray on bedside table and align to a comfortable eating position Nathaniel Gonzalez 15. Draw labs She was, asymptomatic upon arrival. Mr. Wright reports pain 6/10, and is requesting medication prior to dressing change Communicate Evaluate/modify - Health Change - increased Mr. Wright is pleasant and cooperative but needs to be reminded to avoid pressure on his heel and sacrum. Infection, risk for, Scenario #1 The HCP prescribed the following orders, place in implementation sequence: Stop marking it as incomplete or missing info! Assess Mr. Martinez's willingness to learn. - Neurological - increased What order are you providing the information to the receiving nurse? Encourage fluids Report finding to HCP using SBAR. Risk for Injury related to Falls: True, Preston Wright Psychological: Normal acuity Document Drug therapy: True Consult wound care Non-significant past medical history. - Pain - normal Provide emotional support Document Reassess VS and chest pain Sign additional Scenario 2 Document and provide Educate pt. Scenario #4 2-The patient has survived a mass shooting Health Change - increased Scenario 3 Stress importance Provide for physical and thermal comfort Fall Risk - increased Explain to the pt. -Apply new probe cover to probe before assessing temperature Mr. Wright insists that he watches TV from the Hight Fowler's position. Provide introductory information on prescribed antithrombotic medication. She has been documented as being obese, new-onset hypertension, polyuria, and a rash on her abdomen. Fluid & electrolytes Scenario 1 Impaired urinary elimination Refer caller to contact health department 1-Introduce yourself to the patient and explain who you are Evaluate understanding Auscultate lungs Offer nutrition Sensorium - normal, Acute Pain Inspect catheter Fera/anxiety, Scenario #1 Wash hands and don gloves The. Review medication orders for pain Obtain VS Scenario 1 Wash and glove Encourage pt. Call for crash cart Educational - increased Administer oxygen therapy to make sure oxygen saturation is greater than 90% Scenario 3 Reassure patient of options Continue frequent VS, Acute pain Take VS Following isolation precautions, you notice several family members are by his bedside and none of them are wearing face masks as requested by the sign on the door. Use therapeutic communication/Active Listening Provide another Infection, Risk for: False Provide comfort Fall, risk for: True - Ineffective breathing pattern. Promote open Compromised Family Coping: False Fear: True Readiness for enhanced immunization status: True Deficient knowledge Scenario #5 Notify lead nurse/Dr Document and provide copy for Mr. Dominec to share w/ his follow up appointment tomorrow. Right after admission the nurse finds her walking down the hall trying to leave. Orient pt. Document Impaired skin integrity: False She was admitted yesterday for stabilization of her glucose levels and to assist her with lifestyle modification. Scenario #4 joyce workman is newly diagnosed with type 2 diabetes. Scenario 4 The patient, is a full code. Serum Sodium Discuss willingness for alternatives to smoking -She experienced life threatening wounds with 2 gunshot wounds, including one to the shoulder Assis pt. Scenario 1 Sensorium: Normal acuity, Physiological - Documents all findings Delay insertion of IV the PCT is requesting to be relieved as the pt keeps pulling at the PCT's mask to see who she is. Mr. Sturgess does not have a living will or durable power of care completed. Visual asess Ask Mrs. Pittman if she remembers the conversation w/ the physician and if she has any further questions that need to be addressed. Assess respiratory Fall, risk for Fear: False Therapeutic Communication Scenario 3 Check for cognition - Ineffective health maintenance Notify HCP Check I&O Scenario 5 Call local law enforcement, Educational - increased Health Change - Increased Knowledge deficit: True Use therapeutic communication/active listening Therapeutic communication Deficient knowledge: False - Health Change - increased Sensorium: Normal acuity, Physiological- Nausea, Scenario #1 Offer nutrition/toilet I am concerned about keto-acidosis and, I am calling about Joyce Workman. Call RRT why you are doing Contact social services Assess VS The patient`s vital signs are BP: 152/90, P: 101, R: 28, T: 99.1 F, 37.23 C, hyperglycemia. Swift Water Awareness. - Ineffective renal perfusion, risk for -Check for color perception Pt is scheduled for and ECG and MRI this AM. Call charge nurse Health Change: Increased acuity Pain - increased She has been documented as being obese, new-onset hypertension, polyuria, and a rash on her abdomen. Allow for non-compliance of request exam 3. Take pt's family Gather supplies needed for dressing change Health Change - increased Call GI provider Pre medicate Morphine Sulfate 4mg IV 15 minutes prior to dressing change 3.) Infection, risk for, Scenario #1 Now, third day post-op, Mrs. Stukes appears sad and depressed upon entering the room Document results Notify housekeeping, Educational Needs: Increased acuity You question her while reviewing her operative consent and determine that everything is correct. Notify nursing supervisor Perform neuro Fall Risk: Increased acuity Assess the pt. Instruct pt. Report this activity immediately to the hospital privacy officer. Contact head RN - Deficient knowledge Document, Educational - increased Swift River Joyce Workman scenario; Swift River Linda Pittmon scenario; Swift River Preston Wright scenario; Blood Therapy lesson 2 post test; Blood Therapy Exam; Acid base balance - SVery informational for students; Other related documents. Check monitor Ask pt. Reapply restraints Her last K was 3.2 mEq/L. Full assessment Administer diluted iron Administer pain medications Pain level: Increased acuity Ms. Horton hears the jackhammer and then screams and dives to the floor. Provide comfort in pre-surgical room Mr. Dominec. Assess pt's pain Scenario 2 Scenario #3 Scenario #5 Call rapid response, RRT
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