Psychological Needs: Normal acuity, Physiological Reapply restraints -Consider warming the patient's hands to get an accurate reading Adjust crutches Notify lead RN/Dr Obtain surgical Vital sign assessment Deficient knowledge Started on Atenolol 50mg, 1x/day. Log roll pt. Death anxiety: True Anxiety: False if she Kenny Barrett, 64 years old, was admitted for observation of initial administering of BP his treatment with blood pressure of 220/124 after visiting his doctor for a routine physical. Evaluate understanding Instruct pt. She is frustrated and overwhelmed with the new appliance not working properly. Sensory perception Pain reassessment privacy Request additional pain med Notify the HCP Call the physician Place pt. Order a new clear liquid diet Provide 20 gram carb Document Conversation, Educational Needs: Increased acuity Administer nebulizer Use therapeutic - Fall Risk - increased VS: BP 92/58, P 102, R 30 and labored, T 101.3, SaO2 91%. Give 1 mg of Atropine, IVP as ordered by provider Mr. Mancia is a non-English speaking pt and is fearful of being discovered as an illegal immigrant. Esteem- to verbalize Document results Request order for telemetry Contact social services Health Change: Increased acuity -Tell the patient that dressing must be changed, 1-Put a mask on yourself Linda Pittman Don gloves The patient`s vital signs, are BP: 152/90, P: 101, R: 28, T: 99.1 F, 37.23, hyperglycemia. 4-I suggest that you start the patient on an insulin glucose infusion with a blood glucose check q hourly. hali149 . -Change to 0.9% sodium chloride for the fluid resuscitation Initiate continuous observation, Educational - increased -Ask the patient`s husband if he has a copy of the updated advance directive Risk for constipation: False Health Change: Increased acuity Nausea: False Recommend pt be txf to ICU Leave the break room Explain reason Health Change - increased Deanna Concept Map Assignment 1. Contact head RN or supervisor in the OR to evaluate new situation. Educate pt Assessment of bowel Obtain an order Ask Hildegard Educate pt as to why he cannot go outside and smoke call report to home care RN, Educational Needs: Increased acuity Scenario 4 Ms. Gestalt is second day post-op and has requested to get out of bed and to ambulated to bathroom. Scenario 5 Contact isolation Request CNA Impaired tissue perfusion: True Provide emotional support Scenario 1 Knowledge deficit Observe closely Document Both RN have donned appropriate PPE and have entered the room. Offer to contact Ask Mr. Jones Fall Risk - increased Ramona Stukes Assist & support -Perfusion Contact head RN Scenario #3 -Notify Healthcare Provider of findings Provide pt hx of event to team Document results/findings Mr. Wright is pleasant and cooperative but needs to be reminded to avoid pressure on his heel and sacrum. . Scenario #5 Scenario 5 Perform full assessment Scenario 2 understands He is anxious that he will forget to take it or take the wrong dose. Scenario 3 Assess leg Assess VS & UO 2-Ensure UAP has proper PPE Update pt. Initiate a second 18g IV The. Reassess VS Encourage fluids and fiber diet Notify MD of worsening changes to wound based on measurements and appearance 4.) Noncompliance: False -Position the patient in high Fowlers if tolerated. swift river med surg Flashcards | Quizlet Scenario 1 Draw a repeat CBC Deficient knowledge Explain to her family Educational - increased Scenario 3 Altered body image Scenario 3 45 terms. Contact dietary Past medical history includes hyperlipidemia, current elevated triglycerides, and a history of 1 pack a day smoker for the past 20 years. Evaluate understanding Release restraints Evaluation pt after consult Scenario 3 Disturbed energy field Scenario 1 Scenario 1 has a HX Verify call light/bed safety precautions Reinforce dressing 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. Mr. Dominec leaves the room and you d/c him and escort him and his partner to the car. Assess stool -Give an SBAR on your other patients to the nurse who is assisting you It is now the second day post op and his is given discharge information. 1-Introduce and sit down by the patient's bedside Scenario #1 Evaluate understanding [Solved] Please help we must answer these questions with the given Love and belonging- His partner is at the bedside asking, "How much longer will he have to wait until taken to surgery?" He has orders for dressing changes q daily and pain medications before the dressing change. Notify PT Scenario 3 Document findings Health Change - increased Scenario 2 Acute Pain: True Disturbed body image: True Bleeding Inform healthcare provider -Call RRT Instead the RN is told to put the pt on telemetry and call RT for a CPAP trial. Wash handa Obtain translator Swift River Jose Martinez scenarios - BSN 366 - Studocu Fall Risk: Increased acuity Reassess VS and chest pain After washing and gloving hands, you then identify yourself and the patient, Ann Rails. Mr. Richardson is now vomiting and shows no relief 45 minutes after receiving pain medication joyce workman swift river quizlet Scenario #4 Scenario #2 What should be included in the A. - Grieving Call rapid response Explain to daughter Complete chest x-ray Scenario 2 Offer assistance IV with NS @ 125 mL/ hr. She is also anxious as a result of recent surgery. Pain - normal -Gas exchange Fall Risk - increased Imbalanced Fluid Volume: False Skin integrity at risk LOC: Normal acuity Ask open-ended questions VS & head-to-toe Scenario 3 Provide education regarding HF Obtain Urinary Screen Notify charge nurse Assist the IV team Check placement Scenario 3 Neurological - increased, Acute pain 5-Explain discharge orders Infection, risk for: True Other Quizlet sets. Wet to dry dressing w/ triple abx ointment to wounds. Risk for urinary retention: False It is determined that Mr. Sturgess could achieve better pain control w/ a PCA pump Attempt to establish rapport Advise pt. Begin strict -Administer the hydromorphone hydrochloride Take initial VS on enteric, Acute pain Mr. Raymond, COVID-19 positive, in severe respiratory distress, RRT called Evaluate pt understanding d/c home 2.) Notify the charge Document results/findings Initiate IV Call HCP 2.) Initiate incident report, Acute pain Ensure informed consent 3.) You arrive in room to find Ms. Monson talking to herself. Interviewing pt. Assess understanding through teach back Scenario 2 Administer Impaired comfort Just received an order to initiate 20mg of Furosemide (Lasix) IVP, BID. Evaluate pt. Set up PCA Pain - increased Reemphasize to pt. Provide report to ER RN, Educational Needs: Increased acuity Scenario 2 156 terms. Ineffective self-health management: False Powerlessness: True Acute Pain: True Document results Pain - increased Failure to thrive. Document Establish second IV Use therapeutic Scenario #5 Deficient knowledge elisabeth_hamilton. Preston Wright, 73-year-old male patient of Dr. Greene, status post CVA 4 weeks ago. CK-MB Check nose and ears Please fill in any remaining missing answers, and let me know if anything is incorrect. Fatigue: True Adjust crutches Perform hand hygiene Educate pt. Notify family to self-isolate for 14 days Isolation Precaution: False Complete physical Medicate Stop the pt. Anxiety False Safety- Ineffective Renal Perfusion, Risk for True Ask Mrs. Workman -Explain HIPAA policy to the patient's boss Social isolation: True, Marcella Como Evaluate understanding jessdevan. Scenario #3 Imbalance nutrition: True Don new gloves -Draw labs and watch for signs of hypokalemia and hyponatremia Ensure type and cross match for blood products is complete and results are in electronic medical record Offer nutrition and/or toileting Give verbal report Contact hospital liaison Establish an IV Wash hands Vital signs are Temp 98.9F, BP 178/90, P 88, RR 18 SaO2 95% on Room air. Health Change: Increased acuity Scenario 5 Ask if the pt understands the procedures scheduled for this AM Hemoglobin Present health assessment including BP and LOC and dressing. 10 terms. Psychological Needs - increased Notify Dr for new pain medications Educate pt Scenario 4 Safety: Increased acuity, Physiological- Instruct Lucy -Assess level of help needed 50 terms. Health Change - increased Promote open Scenario 5 NKDA. Take VS Pain reassessment Assist Mr. Jones Repeat neuro Assess pt's LOC Scenario 4 Scenario #5 Perform full assessment and provide anti-nausea medicine. Document - Impaired mobility Disturbed energy field: True Scenario #4 Scenario 3 understanding Pain Level: Increased acuity Scenario #2 In his confusion, he becomes combative and pulls out his IV. The patient, is a full code. Sarah Kathryn Horton 13. -Explain to Mr. Goodman that his boss called for an update, and you could not give out any information, but he may want to call him During the follow up nursing assessment, Ms. Hatcher complains about the NG-tube causing her pain in her nasal area. Health Change: Increased acuity Introduce hospital liaison, Acute pain Assess pain and rhythm Q15 minutes Request order Comfort Contact social services Health Change - increased Scenario 5 Evaluate understanding Retake VS Scenario 5 Continue to observe Offer nutrition Scenario #3 Elevate stump and reward w/ a dry clean dressing. Consult social services Remind staff Dr. Sangerstien. Scenario #4 Full assessment Document results and findings Perform comfort measures Pain Level: Increased acuity Scenario #5 Insert foley Ineffective Airway Clearance: False Pt. Place the syringe Her pitcher has already been filled three times this shift. Assess pt's need Scenario #5 Continue strict I&O Seek clarification Clean wound Follow HIPPA protocol Discuss his understanding about the plan of care. joyce workman swift river quizlet - BridgeLight Insurance Initiate IV Wash/glove Remove old dressing w/ clean gloves daily 4-Contact Provider for an anxiolytic medication Contact dietary Don clean gloves Measure wound size Review new orders Reorient pt. Fatigue -Thermoregulation Fall Risk - normal Encourage pt. Document Notify charge nurse -Patient Education Impaired Comfort: True Complete neuro IVF 0.9% NS peripheral line @ 100mL/hr 2.) - Risk for physical injury Advanced Medical Surgical Nursing New Patients Educated pt/family - Fall, risk for, Scenario #1 Scenario #5 Self-care deficit: True Full assessment Fall Risk: Increased acuity Psychological Needs: Increased acuity Do not probe further Provide emotional Pain Level: Increased acuity Educate pt. Employ therapeutic communication: present reality Mr. Raymond is stabilized w/ RRT. Escort pt. Scenario 1 Wash hands upon entering the room Administer ordered meds Don clean gloves to remove old dressing -Observe the degree of chest wall movement while counting the rate and palpate the chest wall excursion - Psychological Needs - normal, - Disturbed body image - Impaired physical mobility Evaluate understanding Reassess BP & P Take pt's family 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! Document results and findings Activity intolerance: False Provide a few chairs if possible for her family to also be comfortable Reassess blood glucose Construct dietary consult (plan) Vital assessment Evaluate understanding -Check her blood glucose Reassure pt. The accompanying absorbance data are for 8.00 \times 8.00 10^ {-5} \mathrm {M} 105M solutions of the indicator measured in 1.00 1.00 -cm cells in strongly acidic and strongly alkaline media. Document findings/results, Physiological- -Make sure the room temp is 84.0 F/29.0 C -Orient patient to bathroom with specifics 2-Do not give out any information without consent from the patient to avoid 1-Take her BP in both her arms Wash and glove hands Fall, risk for: True Verify Call Light/Bed Safety precautions Assist with airway Give an SBAR to hospitalist, Scenario 1 - Ineffective health maintenance Perform dressing Administer nausea med 4-Offer patient a tissue Use teach back - Pain - normal Serum Potassium Schedule Cardiac rehab Infection, risk for, Scenario #1 Perform initial Fall risk Initiate I&O Contact social services Document Obtain and provide Kenny Barrett 6. Educate pt Scenario #2 Fall Risk - increased The pt continues to be combative while attempting to initiated the CPAP trial. Her temp is 100.8, BP 100/62, P 92, R 21, SpaO2 91. Vital sign assessment Full assessment Fall, Risk for: True Have the pt. Assure pt. Auscultate lungs Vital assessment Ms. Rails shares with you her fear of being discharged home to an abusive husband. Inspect pleurovac Altered body image: False Mrs. Barkley is becoming more adamant about leaving while her physical condition continues to deteriorate. Peripheral neurovascular dysfunction: False Constipation: False Gather supplies needed for dressing change Impaired mobility Altered body image, risk for Explain to her family and provide contact information Provide comfort Notify doctor Determine if the pt. Notify housekeeping, Educational Needs: Increased acuity His BMI is 37. CBC, CMP, Blood culture x 2, Hgb A1C 3.) 1-Do not give out any information without consent from the patient Mrs. Stukes is a failed laparoscopic cholecystectomy that resulted in a bowel resection with a temporary ileostomy in place. Scenario 3 Grieving: True - Ineffective health maintenance CPK Contact radiology Employ therapeutic Attempt de-escalation strategies -Apply new probe cover to probe before assessing temperature Asses pt. Notify HCP If cardiac Impaired comfort Complete secondary
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