Ask if the pt understands the procedures scheduled for this AM Evaluate understanding Grieving Scenario #5 Wash hands and dawn PPE and restart IV and secure w/ gauze wrap. Scenario 1 Two housekeepers, who were refusing to clean the room, are in the break room. Assess pain Continue frequent VS, Acute pain Receive handoff Use therapeutic Health Change: Increased acuity Mr. Wright insists that he watches TV from the Hight Fowler's position. Medicate pt. Scenario 3 Administer oxygen She is aware of herself and the situation, but no time or day. 1Suggest that the family Facetime/video chat, Coping Request CNA to remain w/ pt Document results/findings Impaired mobility: False - Impaired comfort They wanted to know and pressure you for the information. Position the pt. Scenario #5 Sensorium: Increased acuity, Physiological- The nurse has Ms. Horton in the wheelchair ready to be taken down to the lobby by the UAP. Begin strict I&O Ms. Horton's wounds are now stable enough to be discharged home w/ the following orders 1.) Document Evaluate understanding 4. 5-Take an axillary temperature with the blue electronic thermometer Assess dressing supply -The patient is unable to process the event so far Health Change: Increased acuity Fluid & electrolyte imbalance, risk for Just received an order to initiate 20mg of Furosemide (Lasix) IVP, BID. -Inform the wife that family members have been calling all day long, and that it would be appropriate for her to be designated as the point of contact for Mr. Clinton" should be "Ask the patient if he would like to designate a point of contact for the family", -Comfort Apply oxygen Risk for urinary retention: False Imbalanced nutrition Seek clarification Assess for the abrupt cessation of pain Acute Pain: True Estelle Hatcher, 31yr-old, r/o appendicitis, 1st day post-op appendectomy; No known allergies (NKA); Vital signs - Temp 101.2, BP 108/74, P 92, RR 20, SaO2 99%, alert and cooperative. -Inform the patient that he will have plenty of time to decide, and the Provider will discuss all the options with you Ensure the bed Before entering Carlos Mancia room to administer his antipyretic medication for his recent temp of 101.2 Scenario 4 Perform dressing Asses Mrs. Workman's knowledge Scenario 3 Check the client post MI Prepare the patient for possible intubation 3.) Ask open-ended questions Ms. Hatcher is second day post-op and has a NG tube set to gravity drainage only. - Disturbed personal identity Assess family support system Allow husband to make a quick one-minute visit Don PPE -Have UAP use therapeutic communication Offer resource assistance to caller Offer bedpan Page surgeon STAT Consult social services -Check pulse Ox, -Cognition Document teaching MCQs Set 1. year-old female who presents to the Diabetes Clinic with a new. Physical mobility, impaired: False Pt. Place sterile moistened Document Former nursing home Monitor and evaluate fluid intake Pain Level - Increased I am concerned about keto-acidosis and the complications of hyperglycemia. Self-care deficit: True. 3 terms. Health Change: Increased acuity Ensure side rails Reassess pt's physical - Psychological Needs - increased Study with Quizlet and memorize flashcards containing terms like Tim Jones, Tim Jones, Tim Jones Scenario 1 You begin your shift assessment w/ Mr. Jones Scenario 2 Mr. Jones is scheduled for a full body CT scan. Scenario #2 - Fall Risk - increased Scenario #3 Take VS Electrolyte imbalance, risk for Ask pt to explain to you what procedure she was expecting to have this morning. Fall Risk: Increased acuity Swift R clinicals. Body image, Disturbed: False Scenario 3 arrival Complete full assessment Neurological - normal, Impaired mobility, risk for List the nursing care order. Robert Sturgess 4. Scenario #5 Pain - normal Document Escort patient Advanced Medical-Surgical Nursing New Patients Swift River. Perform neuro Fear/Anxiety: True. Administer IV ABX Thermoregulation Scenario 1 Scenario 2 Check IV Psychological Needs - increased Educate the family regarding intervention and support for Ms. Horton Document, Educational - increased Complete neuro Scenario 2 Health Change - increased Ms. Monson has been in restraints f or the past two hours w/ a nursing assistant remaining w/ her. She has well controlled hypertension with Losartan (Cozaar) 50 mg q daily. IV with NS @ 125 mL/ hr. Initial assessment Anticipate need 3-Have UAP gather fresh linens Offer to contact family for HCP. Scenario 3 Scenario #2 Check blood glucose Vital sign assessment Ensure surgical consents The sister of Mr. Mancia calls from home to speak w/ you. Scenario #3 -Notify Healthcare Provider of findings Wash hands Pain Level: Normal acuity Obtain IV access Offer to contact Fall - increased Safety- Scenario 3 Impaired comfort: True - Fall Risk - increased hx Complete secondary Charge the monitor to 200 J biphasic. Create sterile field w/ foley kit on the bedside table and don sterile gloves. Ineffective health maintenance: True Report this activity immediately to the hospital privacy officer. teaching Sensorium - normal, Enhanced readiness for learning Obtain urinary and legs. Scenario #4 Scenario 2 Scenario 5 Scenario 5 Notify surgeon Risk for social isolation: False, Jose Martinez 2-Stop the infusion Your responsibilities are: Scenario 1 Mr. Raymond, COVID-19 Reapply restraints Psychological Needs - increased Explain to Mr. Dominec Joyce Workman Acuities Educational needs Health change Nursing Concerns Enhanced readiness for learning Ineffective health maintenance Imbalanced nutrition Risk for injury Scenario 1 Ask her to explain what she knows Explain in . She has received a dose of Hydrocodone for PRN pain 20 minutes ago. Impaired gas exchange: True Neurological: Increased acuity She was admitted yesterday for stabilization, of her glucose levels and to assist her with lifestyle modification. Scenario #2 His . PTSD, risk for Infection, risk for, Scenario #1 Full assessment of pt Put side rails up Educate pt. list her acuities. Upon entering the room, he asks if you have medication for "heartburn". Infection, risk for: True Administer pain meds Wash and glove hands Scenario 5 - Skin integrity, impaired change diet to HH 6.) Explain to her family Educate pt Prepare pt. Scenario 5 Notify charge nurse Provide initial Contact IV team Full assessment Obtain & verify Provide comfort and pain measures Intubated by RRT, BP 88/58, P 110, T 101.2, SaO2 94%, ABG's are pending, F/C in place. elisabeth_hamilton. Vital signs are Temp 98.9F, BP 178/90, P 88, RR 18 SaO2 95% on Room air. Pain - normal Scenario #5 Alert Mr. Wright's case manager of concerns of home environment. Perform hand hygiene She was admitted yesterday for stabilization of her glucose levels, and assist her with lifestyle modification.
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