They feel that you should share w/ them if he was a "real AIDS" pt or not. Shae_Quinn9. Nutrition consult Wash & glove Initiate IV fluids to peripheral site see the plan of care: 1.) Check foley Spiritual distress: False Ask the pt about In his confusion, he becomes combative and pulls out his IV. Notify social services Call security 45 terms. Past medical history includes hyperlipidemia, current elevated triglycerides, and a history of 1 pack a day smoker for the past 20 years. Complete neuro Nausea: False He is anxious that he will forget to take it or take the wrong dose. Charge the monitor Psychological Needs - normal Acute Pain: True Perform a focused assessment Safety: Increased acuity, Physiological- Ambulates with minimal assistance. Safety- Sleep deprivation: False Draw stat D-Dimer Review pain medication order Acute Pain: True Reassure pt. Assess pt. Chronic pain: False She presses the call light w/ questions about who her RN will be and her NG-tube. Interviewing pt. Sensorium - normal, Acute pain Cal rapid response Impaired mobility, risk for 1. Safety - Esteem - Deficient diversional activity: False Psychological Needs: Normal acuity Apply fall risk bracelet Health Change - increased Administer prescribed Log roll pt. Don 2nd set why he will Scenario #3 Document Explain the necessary procedure Psychological Needs: Normal acuity Visual assess -Assist patient in performing hand hygiene - Noncompliance Advise pt. Julia Monroe Ineffective coping Obtain urinary Scenario #5 The CNA reports the blood pressure was 130/86 an hour ago Observe for bleeding Administer Fall, risk for Assess the injury for presence of necrotic tissue and amount of exudate. Fall Risk: Normal acuity Evaluate the following expression containing percent. Scenario #4 Evaluate outcome of dietary plan She also takes Metformin to control her Type 2 Diabetes. Donald Lyles, 52-year old male, was admitted yesterday evening for stabilization of his uncontrolled type II diabetes. Evaluate/modify. Scenario 2 Esteem- Follow HIPPA protocol Impaired mobility: False Scenario 5 - Impaired comfort Review with Mrs. Workman Scenario 3 Psychological Needs: Increased acuity Escort pt to ER for a physical and psychological evaluation Fall Risk: Increased acuity has a HX Reassess respiratory After washing and gloving hands, you then identify yourself and the patient, Ann Rails. Mr. Sturgess is uncomfortable w/ experiencing urinary frequency that keeps him from resting to verbalize Assess/inspect I HAVE INCLUDED ALL THE INFO! Scenario 5 Pain Level: Normal acuity MCQs Set 1. Call for code -Notify Healthcare Provider of findings Check pedal cap refill Wash hands and don PPE 1-Enter the room, perform hand hygiene, and cancel the call light Notify PT Wash hands teaching Give NS liter bolus 10 terms. 5-Inform the team that the patient has an advance directive to include no intubation and no CPR Scenario #3 Mr. Lyles responded to the first cardioversion, and is now in a sinus-Brady w/ a second-degree heart block. - Neurological - normal The RN calls the attending provider requesting that Ms. Barkley be txf to ICU but there are no rooms available. Discuss his understanding about the plan of care. Notify the charge nurse and house supervisor of the syringe found in bed Knowledge deficit Assess IV Explain to the wife Insert new IV above prior site or opposite limb Empty foley VS assessments Insert new IV Health Change - increased Provide comfort measures Ms. Rails shares with you her fear of being discharged home to an abusive husband. on O2 Hold next dose of Atenolol if BP <130/80 -Test patient's vision with number of fingers, objects, etc. impaired comfort Reassess pt. Scenario #5 Repeat 1mg of Atropine administration w/in 3-5 minutes of first dose Wet to dry dressing w/ triple abx ointment to wounds. Fluid status Elevate HOB Have pt. Educate pt, - Educational Needs - increased Nausea, risk for Prepare the patient for possible intubation PT to educate pt Psychological Needs: Increased acuity Scenario 3 -Prepare SBAR for arriving team Scenario 3 Anxiety: True Document Scenario #2 Notify lead nurse/Dr Safety- Obtain VS Psychological needs: Normal acuity Nausea Rape-trauma syndrome: True Scenario #3 Encourage Mr. Wright Follow HIPAA Decisional conflict: False Scenario #3 Scenario #4 Check proper positioning Discuss w/ pt. Document Don gloves & assist pt. Review medication Allow family to remain 3-Have UAP gather fresh linens Take VS Impaired Memory: False Restart IV Deficient knowledge Pt received furosemide Lasix 20mg, IVP x2, on Claforan Q4, and on sliding scale insulin. Imbalanced nutrition Reassess its VS Wash hands Full assessment Sit with the pt. Elevate extremity - Physical mobility, impaired - Deficient knowledge Instead the RN is told to put the pt on telemetry and call RT for a CPAP trial. Provide Morphine sulfate IVP as prescribed Assess the pt. You enter patient's room. Fall Risk - Increased Scenario 5 The plan is to discharge Ms. Yu back to her assisted living facility. Auscultate lungs PT to educate Verified answer. CK-MB 6.8 Inform the pt. Restate or paraphrase pt statements Provide report, - Educational - increased She has been documented as being obese, new-onset hypertension, polyuria, and a rash on her abdomen. Contact nursing supervisor understanding Make referral Bleeding Evaluate understanding Prepare Mrs. Knox's body Document Place pt. Pain Level: Increased acuity Explain to the pt. Scenario #3 Compromised Family Coping: False The. Scenario 4 Explain in lay . Neurological - normal Communicate w/ the pt therapeutically Assist RT - Powerlessness Ms. Barkley continues to deteriorate and is shouting for her family. Pt. ID pt. Scenario 2 Start O2 Reassure pt. Ineffective Self-Health Management: False 4-Observe the complete respiratory cycle Infection, risk for, Scenario #1 Constipation, risk for: True He is now in V-tach w/ a weak pulse and BP 70/40. Scenario 1 Visual assessment Scenario #4 You shouldn't, "Are you okay? Pain reassessment Document Teach the pt. Pt. Encourage Mr. Clinton, Educational - increased Scenario 5 Notify Dr if condition is abnormal Mr. Duncan is now complaining of feeling "dizzy" when he stands Temperature is now 102.8 Release restraints/full range of motion Administer pain meds Marcella Como 7. Include pt condition Chang in shift report Scenario 4 Other Quizlet sets. -Evaluate patient understanding of plan of care Offer bedpan Deficient knowledge: False he chooses to go home and see the dr tomorrow in his office. Scenario 5 Evaluate patient learning Restart pt's IV Scenario #4 Impaired skin integrity: False Sensorium: Normal acuity, Physiological- Scenario 2 Call Mr. Jones's children Pain - increased Notify MD for F/C Scenario #5 - Hopelessness During the follow up nursing assessment, Ms. Hatcher complains about the NG-tube causing her pain in her nasal area. Check pleurovac Dressing change q 24 hours to RT thighs and rt shoulder. The dx tests were completed and Dr. Gray has informed the pt of the dx of HF and tx w/ digoxin. Provide a diversional Risk for infection: True, Donald Lyles Infection, Risk for: True. Assess Ms. Horton's Scenario 1 Full assessment Administer pain meds Scenario #3 Verify call light VS are BP 128/82, P 90, R 22, T 99.2, Scenario 1 Impaired gas exchange: False -Evaluate pain on a scale of 1-10 Use therapeutic communication/Active Listening -Have the next of kin sign the operative consent if available. Scenario #3 Pain - normal Present health assessment You now arrive in the recovery unit one hour post-surgery and you are told that the surgery went well. 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 . Fall Risk: Normal acuity Notify HCP Fall Risk: Increased acuity to apply ShannonLamb1. Scenario #3 Comfort the pt Place pt. - Social isolation, risk for, Scenario #1 Reassess pt's VS Scenario 3 Meet with daughter Call local law enforcement, Educational - increased Encourage pt. Scenario 1 mary_heath32. Scenario #4 -She experienced life threatening wounds with 2 gunshot wounds, including one to the shoulder Notify HCP Impaired mobility, risk for Provide supplies and needed instructions Knowledge deficit: False Verify call light Observe closely Risk for infection Initiate anti-psychotic meds Safety- Scenario 5 Evaluate understanding Tell the mother that visitors are welcome 3-Comfort and orient patient to person, place, and time. Instruct Lucy Assess pleurovac Inform admitting physician Risk for injury, Scenario #1 - Disturbed body image, Scenario #1 Fall risk Scenario 1 Explain to pt. Place pt. Disturbed Sensory Perception False Apply new dressing The nurse has Ms. Horton in the wheelchair ready to be taken down to the lobby by the UAP. Continue to encourage Evaluate understanding Deficient knowledge CK-MB Scenario 3 Scenario 5 Begin list of medications Apply O2 Inform healthcare provider Administer levofloxacin as ordered 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! Grieving: False Administer medication I am concerned about keto-acidosis and the complications of hyperglycemia. Document results Obtain a sitter Obtain & verify Monitor neurovascular status assessing skin color, temp, sensation and pulses above amputation. Assess leg Scenario 5 Fall Risk: Increased acuity What order are you providing the information to the receiving nurse? -IV Antibiotics Scenario #5 Use therapeutic Educate pt Remain with pt. Contact IV team Fall, Risk for: True Scenario 4 Scenario #5 statement Retrieve cast removal tool Don Johnson Room 306. Upon entering the room, you find Ms. Rails sleeping. -Assess level of help needed Scenario 3 Perform pain reassessment Full assessment - Impaired mobility Discuss with HCP Educate pt regarding RRT's purpose, Physiological Educate pt - Health Change - increased Verify with blood bank Contact charge nurse Scenario 3 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. Peripheral neurovascualr dysfunction: False, Viola Cumble Foul odor noted w/ green drainage coming from toenail beds. -Inform healthcare provider that the advance directive was not completed, but one is being executed now Administer ordered meds Inspect site -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 Mr. Sturgess is recently dx w/ metastatic cancer of colon and he and his family have chosen only palliative care. Wash and glove hands Pain - normal Leave the break room Disturbed body, Scenario #1 Post op day 3 time for dressing change stump. Initiate a second 18g IV Explore new ways Functional ability Present health assessment including BP and LOC and dressing. Start O2 @ 2LNC Inspect cast site Assess current pain Educate pt. Orient pt. Administer ABX & start morphine Educate Ms. Horton Initiate IV Pain Level - Increased Assess I/O and possible reasoning understands Upon entering the room, what is the appropriate order of events for the RN to take? Document findings Document results - Impaired mobility Disturbed body image: True Her husband who is present stats, "I thought it was just a lumpectomy she was having this morning." Pain Level: Normal acuity Notify cath lab for stat cardiac cath Educate pt. Inform his partner that everything is being done to keep him comfortable. Obtain translator Fear: False Using therapeutic Before entering Carlos Mancia room to administer his antipyretic medication for his recent temp of 101.2 2-Recognize patient is in respiratory distress with an unknown etiology Obtaintelemetry Provide Mrs. Workman Prescribed medication Scenario #4 Ask PCT to secure mask better, and inform her that there is no replacement for her. Check IV Report and document results - Fall Risk - increased Discuss options -Perfusion Pt was admitted yesterday afternoon w/ HTN, BP 178/90, P 88. Scenario #2 Document results and findings Document It is now 2 wks later; Mrs. Smith has returned. Evaluate understanding lOMoARcPSD|7327774 New Patients Swift river med . Offer to contact family for HCP. Pain Level: Normal acuity Nausea, risk for Assess Ms. Horton's orientation status -Sit quietly with the patient allowing them enough time to respond She is disoriented and believes the nursing staff is trying to kill her. Inform pt. Mr. Richardson is now vomiting and shows no relief 45 minutes after receiving pain medication report to charge nurse/head nurse the need for staff education. - Pain - increased Ensure there is a full Med-Surg SR. 83 terms. 4. Explain that he will Communicate Deficient knowledge Complete pre-op Other Quizlet sets. -Gas exchange Scenario #2 Serum Potassium Obtain IV access and draw initial labs Connect telemetry Discuss his understanding Announce to CODE Provide a few chairs -Explain to Mrs. Barkley that you are going to change her linens Document Do not probe Ms. Gestalt is now complaining of fever and chills Health Change: Increased acuity You arrive in room to find Ms. Monson talking to herself. Altered Body Image: True 2-Have the patient rest in the same position and repeat BP assessment in 15 minutes Educate pt Remove NG Give tylenol Use therapeutic communication/active listening Ensure pressure dressing Perform comfort measures Assist anesthesia Re-assess pt -Wipe down chair with disinfectant Educate pt She was admitted yesterday for stabilization . Pre-medicate -Rate patient's pain on a scale of 1-10To determine level of pain for intervention Provide operative summary Provide for physical and thermal comfort Ineffective breathing pattern, Scenario #1 Use therapeutic communication/Active listening Use therapeutic -Thermoregulation -Ask the patient if she has reviewed her advance directive recently. Educate pt-STD's and pregnancy Notify respiratory therapy Scenario #3 - Fall ,risk for 1Suggest that the family Facetime/video chat, Coping She has sleep apnea, and she brought her CPAP machine. She appears short of breath when talking. Scenario 1 2-Tell the patient that it has come back, and his Provider will discuss the findings Scenario #3 - Bleeding, risk for Fluid & electrolyte imbalance, risk for Offer UAP Attempt to restart IV Scenario 5 Impaired comfort: True Set-up on 100% non-rebreather Wash handa Her HbA1C is. Promote open communication between mr. and Mrs. Martinez Document in the pt record Pt and family should verbalize understanding of d/c instructions 3 -Check the chart for the updated advance directive Scenario 4 Scenario #2 -Grief Scenario #5 Scenario 4 Scenario 3 Scenario #5 Ms. Getts is now complaining of sudden sharp, substernal chest pain, very short of breath and is profusely diaphoretic. Provide initial Reassess environment Scenario 2 Assess extremity -Inspect cast integrity, capillary refill, and skin temperature Pain, Acute: True Proved PRN Review new orders Self-care deficit: True Ms. Monson has been in restraints f or the past two hours w/ a nursing assistant remaining w/ her. Notify doctor She was asymptomatic upon arrival. Risk for injury, Scenario #1 She is 85 years old and has a history of osteoarthritis and cataracts. Study with Quizlet and memorize flashcards containing terms like Linda Pittmon, Kenny Barret, Joyce Workman and more. Impaired urinary elimination Health Change: Increased acuity Wash and glove hands Scenario #3 Scenario #5 Assess for fall Notify HCP Contact Social Services Assess insertion site Assess pain and rhythm Q15 minutes Report finding to HCP using SBAR. Marcella Como is now more talkative and shares with you that she is going to cooperate and wants to press charges against the assailant. Orient Roger mi mundo en otra lengua. Call RRT, rapidly prioritize the following Scenario #6 Pain level: Increased acuity Psychological Needs - normal - Skin integrity, impaired IV with NS @ 125 mL/ hr. Skin integrity at risk: True Robert Sturgess 4. Review current A group of university students conduct a survey regarding menstrual pain for their biology subject. Assess and document the condition of the skin surrounding the pressure injury in terms of color, temperature, texture and moisture. Scenario 4 Alert Mr. Wright's case manager Check time from one source Neurological: Increased acuity Concepts of Nursing IV 100% (3) Swift River Joyce Workman scenario. Therapeutic communication Bleeding, risk for: True Psychological Needs - increased Acute Pain False Before this, I recommend an ABG be completed to check the patient`s pH to confirm ketoacidosis, -Intracranial Regulation Follow up w/ regular HCP in 1 week 4.) Explain to daughter Treat pt. privacy Sterile NS wet-to-dry dressing changes daily 2.) Evaluate understanding Evaluate understanding 4. Health Change: Increased acuity 4-I suggest that you start the patient on an insulin glucose infusion with a blood glucose check q hourly. Do not probe further Scenario 5 Ask pt to explain to you what procedure she was expecting to have this morning. Don Johnson, There was a warehouse fire that quickly spread to an adjoining neighborhood. Notify doctor -Reassess the burn area to recalculate the fluid resuscitation. NrsSR22. Full assessment Sexuality, Scenario #1 You have entered the room to administer the pts morning medication, atenolol 50mg. Tell the mother that you understand Notify Dr for new pain medications Consult wound care 3 Multiple bruises to the back Start and IV Assess for the abrupt Inform his partner consult social service Pt is complaining of pain in her shoulder and thigh 7/10 Impaired mobility, risk for Scenario #5 Neurological - normal, Chronic pain Fall Risk: True Ineffective self-health management: False Complete full pt. Provide information, Educational Needs - increased Reorient pt to person, place & time Scenario 5 Explain to Mrs. Whitmore Ensure IV access Fall risk, Scenario #1 She has been documented as being obese, new-onset hypertension, polyuria, and a rash on her abdomen. Joyce Workman Scenario 1 Mrs. Workman presented to the diabetes clinic and provided a 24- hour food recall. Document Social isolation, Scenario #1 - Health Change - increased Educate pt Provide comfort Allow for non-compliance of request She is frustrated and overwhelmed with the new appliance not working properly. Safety- Provide pt. Scenario 3 Deficient Fluid Volume, Risk for: True Health Change: Increased acuity Deficient knowledge Explain to Mr. and Mrs. Fear of death Determine from medical record if partner is aware of his recent AIDS dx. Scenario #5 Request order for telemetry -Reassure patient Pain Level: Increased acuity Assess pt. Notify charge nurse Teach pt. Psychological Needs: Increased acuity Educate pt Pain Level: Increased acuity Take VS Place personal aspirin Encourage to ambulate w/ assistance to void if needed 1-Take her BP in both her arms Notify housekeeping, Educational - increased Assist RT to initiate CPAP trial Mr. Mancia is a non-English speaking pt and is fearful of being discovered as an illegal immigrant. Reorient pt to setting using therapeutic communication Evaluate understanding Readiness for self-care enhancement: True Notify the HCP of absence of Advanced Directive and the families request to intubate. Scenario 2 He has been informed that for the next 18 months he should take antithrombotic therapy daily. Repeat H&H Educate about recovery from appendectomy and care to wound. -The patient is still anxious, continue to comfort and reassure her, -Comfort Scenario #3 Chronic Pain: False - Health Change - increased Joyce Workman, Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Ask the patient when the advance directive was last updated As Ms. Horton is waiting by the exterior hospital door, construction workers are on the road working w/ a jackhammer. Risk for constipation: False Scenario 1 Consult wound care Continue frequent VS, Acute pain Full assessment Contact HCP -Obtain witnesses to sign an advance directive Scenario #4 Connect telemetry She was admitted yesterday for stabilization of her glucose levels, and assist her with lifestyle modification. Stay with pt. Scenario #2 Attempt to establish rapport Anxiety: True Pain, Acute: False Scenario #2 Infection, risk for, Scenario #1 Document, - Educational Needs - increased Check patency -Consider warming the patient's hands to get an accurate reading You tell the pt you will be glad to check-on what is available for relief of his "heartburn" after you complete his physical assessment. Scenario 3 Acute Pain: True Pain - normal Educate pt. Contact family Bleeding: False Scenario #4 Monitor neurovascular Psychological Needs: Normal acuity, Physiological- Transport pt. Psychological Needs: Increased acuity Notify the social worker, Acute pain Remind pt. Non-significant past medical history. Document Psychological Needs - increased, Acute pain Pain - increased Scenario #3 Scenario #4 Educate pt. Make referral Ensure informed consent for procedures is signed Ask pt. Psychological Needs - increased Explain to Mr. Dominec Scenario #2 Therapeutic communication Impaired mobility When help arrives, pass off chest compressions and begin respiration's 2-Do not give out any information without consent from the patient This survey aimed to determine the frequency and symptoms of dysmenorrhea, as identified by differen. Don appropriate PPE Psychological Needs: Normal acuity, Physiological - Psychological Needs - increased Begin post op education for day one Re-assess BP and pulse. Please fill in any remaining missing answers, and let me know if anything is incorrect. -Determine cognition by asking questions to determine if she knows who, where, and what happened Medicate Instruct pt not to get out of bed w/o assistance Provide information to Mr. and Mrs. Martinez regarding support groups, Educational Needs: Increased acuity Instruct Lucy to assist in maintaining pt position and field sterility Provide emotional support Ensure the pt. Therapeutic communication w/ pt Talk w/ her stating surgery is over and she did great Pale pt. He refuses to comply with dietary recommendations. Sleep deprivation: False. Restart new IV Sign additional Multiple burn injuries have overwhelmed the local hospitals. -Wait until anesthesia evaluates the patient and have them assist in restarting the IV. Health Change - increased Teach pt. Educate patient Offer resource assistance to caller and legs. Scenario #2 Document Conversation, Educational Needs: Increased acuity Neurological - normal Explain to pt. Notify MD Provide 20 gram carb Skin integrity: False, Charlie Raymond Assist pt. Health Change - increased -Request assistance with your other patients and determine family's availability to stay with the patient Offer bedpan Educate pt Infection Obtain burn sheets Use therapeutic Evaluate understanding Document Impaired tissue perfusion: True -Ask the patient`s husband if he has a copy of the updated advance directive Anxiety: True Provide morphine immediately. Start O2 100% Use therapeutic communication/active listening Document and accompany, - Educational Needs - increased Document results and findings Legal in Canada since June 2016 Implications? Document results/findings Scenario #3 Wash hands Provide morphine Complete incidence report, Educational - increased Later in morning care, Ms. Como requests o take a shower stating she feels 'dirty'. 2-Have nursing staff introduce themselves and explain their role upon entering the room Wash and glove hands Obtain translator Pain - increased Full assessment including both lying/standing She was asymptomatic upon arrival. Contact IV team Evaluate medication effectiveness Administer Scenario 1 Use therapeutic communication to explain necessary procedure. She receives her AM medications including levothyroxie, diltiazem and digoxin. Mr. Lyles calls you via the call light. Ineffective Coping: False She has well controlled hypertension with Losartan (Cozaar) 50 mg q daily. Initiate head-to-toe Assist pt. Educate pt. -Review of body systems and evaluate pain on a scale of 1-10 Fall Risk - increased -Introduce UAP and Mrs. Barkley to each other Assess pt's sputum Mr. Raymond weighs 260 lbs. Assess Mr. Martinez's willingness to learn. Fall Risk: Increased acuity Scenario #2 Assess for therapeutic Teach pt. Reassure pt. 2-The patient has survived a mass shooting Scenario #5 Deficient knowledge: True Sensorium - normal, Scenario #1 Secure sitter to stay w/ Ms. Barkley after the insertion of the new IV. Impaired gas exchange: True Receive handoff Offer assistance Blood lab tests 5.) Risk for malnutrition: True Obtain assistance Pt has a hx of COPD, HTN, DM II, and a recent MI. Initial assessment Now, third day post-op, Mrs. Stukes appears sad and depressed upon entering the room Scenario #4 Notify Cath lab Inspect pleurovac Seek clarification Check I/O for possible dehydration He has been readmitted for a red spot on his sacrum of 1 cm and a 2 cm blister on his right heel. ", Scenario 1 - Impaired physical mobility Scenario #4 Make sure O2 mask is secure and free of sputum. . Scenario 2 Cultural competence Sensory perception Acute Pain: True Secure dressing place with tape 3-Switch pulse ox to the right hand Assess last medication Seek clarification Risk for injury at home, Scenario #1 -Sit at the patient's eye level and ensure they can see your lip movement and facial expression - Ineffective breathing pattern. 1 Ask for a copy of the advance directive jessdevan. - Psychological Needs - increased, - Acute pain Deficient knowledge Assess stool Encourage Mr. Wright to include high protein snacks in his diet Guide her back to her room while teaching her that her isolation is to protect others including her family. Have nursing personnel in the room when family visit, Gas exchange Post CVA, he has developed some aphasia and is having difficulty with verbal communication. Virginia Smith Notify lead RN/Dr You are now preparing for d/c. Provide education regarding HF Apply oxygen Document, Acute pain Complete full assessment Fall Risk - increased Scenario #2 Assess pain Scenario #5 Psychological Needs - normal Provide education Reapply restraints Upon entering the room, you find Mr. Sturgess is quiet, appears tense and rigid but states, "I am feeling fine." Fall, Risk for: True -Contact the appropriate department to see the status of the advance directive The sister of Mr. Mancia calls from home to speak w/ you. Fall, risk for Scenario 1 Anxiety: True IV fluids of D5 1/2 NS are infusing at 100 mL/hour to his right forearm. Safety: Increased acuity She has active bowel sounds Assess pt's pain Scenario 4 -Provide PRN pain medications indicated. Ms. Gestalt capillary refilling is now 6 seconds below cast site, extremity is swollen and cold to the touch Reapply restraints -Have UAP use therapeutic communication In the afternoon, Ms. Como is stating that she does not want to see her husband or any visitors.

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