Talk with Mr. Jones Document, Acute pain Document results Document Vital signs are to be taken BID and it is now time 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. Scenario #5 Scenario #4 Sexuality, Scenario #1 VS are BP 80/40, P 46, R 16, (pt now intubated and ventilated by Respiratory Therapy), Scenario 1 Foul odor noted w/ green drainage coming from toenail beds. Educate pt. Document results and findings Explain HIPAA Contact power of attorney Scenario #2 Kathy Gestalt 9. Esteem- Psychological Needs - increased Health Change - increased Evaluate/modify. Gather supplies needed for dressing change Educate pt Scenario 1 - Ineffective breathing pattern. - Fall ,risk for Alert Mr. Wright's case manager Provide introductory information on prescribed antithrombotic medication. Ongoing debates? Educate patient Swift River- Med Surg Flashcards | Quizlet Scenario 5 Notify housekeeping, Educational - increased Asses for mediastinal shift Right after admission the nurse finds her walking down the hall trying to leave. Administer IV ABX Obtain translator Auscultate lungs -Ask the patient`s husband if he has a copy of the updated advance directive Assess last medication Mrs. Smith's surgery has now ended. Scenario 2 Perform circulatory Fall, risk for Obtain and provide the ID MD contact information for him. 2.) Measure wound size at greatest length, width and depth using a disposable paper tape measure. Scenario #4 Swift River Medical-Surgical Flashcards | Quizlet Perform a focused assessment Scenario 2 Give ASA Document Educate pt Proved additional teaching Scenario 1 Safety- Reassess pt's physical Impaired home maintenance mgmg r/t client or family: False Therapeutic communication w/ pt 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. Sensorium: Increased acuity, Physiological- Scenario 3 -Apply new probe cover to probe before assessing temperature Impaired gas exchange: False Neurological - normal Peripheral neurovascular dysfunction, risk for Impaired mobility Scenario #4 Obtain VS Infection, risk for, Scenario #1 Scenario #2 Have family step out After your AM assessment, the pt's call light goes on and she is complaining of nause, abd pain, and seeing "yellow circles". She was, asymptomatic upon arrival. [Solved] Please help we must answer these questions with the given The RN calls the attending provider requesting that Ms. Barkley be txf to ICU but there are no rooms available. Scenario #3 Initial assessment -Ask the patient if she has reviewed her advance directive recently. Psychological Needs - increased Scenario 1 3-Supplement Oxygen Ramona Stukes Sleep Deprivation: False. Request additional pain med Allow for non-compliance Document Impaired skin integrity: False Scenario #4 Safety: Increased acuity, Physiological - Assess pt's ABCs - Psychological Needs - increased Sensorium - normal, Deficient fluid volume Complete full assessment Enter the room after taking VS. Scenario 5 understands Educate pt. Safety- Stop the platelets river part Answers to the questions - Estelle Hatcher, 31yr - Studocu She has been documented as being obese, new-onset hypertension, polyuria, and a rash on her abdomen. Decreased cardio tissue perfusion: False Scenario #3 Notify HCP Acute Pain: True Comfort the pt Report Mr. Martinez's Both RN have donned appropriate PPE and have entered the room. Scenario #5 Psychological Needs - increased Wet to dry dressing w/ triple abx ointment to wounds. Teach pt. Initiate IV fluids to peripheral site PT has been getting the patient up with a walker and she is able to take a few steps. -Have TDD device on hand Health Change - increased Scenario 2 Scenario #5 Adjust crutches Complete full assessment Ask charge nurse, Educational - increased Establish large IV access Infection, risk for, Scenario #1 -Metabolism - Health Change - increased Educate pt. Create sterile field w/ foley kit on the bedside table and don sterile gloves. D/C instruction Sensorium: Normal acuity, Physiological- Scenario 1 Scenario #5 Notify lead RN/ DR of new circumstances Encourage Notify lead nurse Obtain a sitter Health Change - increased Deficient knowledge Remain w/ pt. Offer to the family Scenario 5 Administer PRN Disturbed body image: True Documents all interactions Fall Risk: Increased acuity Risk for physical injury: True Scenario #4 Scenario #5 -Gas exchange Scenario #4 Disturbed energy field: True Review pain Scenario 2 Decisional conflict: False Instruct Lucy to assist in maintaining pt position and field sterility Call security Fall Risk - increased Collect supplies CPK She is requesting the names and home phone number for the wound care nurse who saw Mrs. Stukes while she was an inpatient. Wash and glove hands report to charge nurse/head nurse the need for staff education. Acquire daily weight Administer oxygen John Duncan Room 302 Joyce Workman Room 303 Meds for new dx diabetes? Perform comfort Encourage fluids and fiber diet Notify Cath lab Continue to assist joyce workman swift river quizlet joyce workman swift river quizlet. VS reassessment Scenario #4 The labs return w/ digoxin level of 10.5 ng/mL, K 5.3 mEq/L. Sensorium - normal, - Acute pain Encourage use of IS What was the priority nursing assessment (s)?-Russel Montgomery- Spinal Injury: assess neuro, musculoskeletal, respiratory-Thomas Bechman- Gout &amp; Dementia: assess integumentary, neuro, musculoskeletal, endocrine (for levothyroxine) -Louis Hutchinson- Amyotrophic lateral sclerosis (ALS): musculoskeletal, neurological, integumentary Document Scenario 3 Pain - normal Scenario #5 Scenario 4 VS are BP 128/82, P 90, R 22, T 99.2, Scenario 1 Inform pt. 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. Swift R clinicals. Check pt's chart Remain w/ pt. Grieving: False Linda Pittmon Room 304 Glucose level? Virtual Clinical- Swift River Week 4. Document findings Instruct pt to lie supine for 6 hours Scenario 2 Spiritual distress: False Scenario #2 Apply NC O2 Notify HCP Scenario #2 Scenario 4 Assess/inspect Reassess pt. She has been documented as being obese, new-onset hypertension, polyuria, and a rash on her abdomen. Scenario 4 Isolation precautions: False Talk w/ her stating surgery is over and she did great Ensure pressure dressing is in place Provide for physical Scenario #3 Comfort the pt Scenario 2 Scenario #4 Neurological - normal of protocols Fall Risk - increased Scenario 5 Fall Risk - increased Explain to the pt. Pain - increased - Powerlessness, Scenario #1 Tom Richardson Ensure side rails Provide therapeutic Introduce yourself/identify pt Altered body image Medicate Evaluate/modify plan of care Risk for constipation: False Mr. Raymond weighs 260 lbs. Educate pt hali149 . Ms. Barkley continues to deteriorate and is shouting for her family. Attempt to restart IV Esteem- Make sure accurate wt. Contact HCP Scenario 3 Reassess pts VS in 3-5 minutes: BP 85/44, P 52, R 16 (pt intubated and vented by RT) Pain - increased Assess documented pain You are now preparing for d/c. Assess the pt Pain - increased Scenario #5 Wash hands Family at beside. Post CVA, he has developed some aphasia and is having difficulty with verbal communication. Scenario 1 Wash hands and dawn PPE and restart IV and secure w/ gauze wrap. Document results/findings Attempt to establish rapport Verify call light/bed safety precautions Scenario 4 - Sensorium - normal, - Fatigue Obtain translator Scenario #3 Scenario #3 Scenario 2 4 Psychological abuse Psychological Needs: Increased acuity, Physiological- Assess pt's sputum Could he have another heart attack? Inspect catheter -Make sure the room temp is 84.0 F/29.0 C Allow visitors to enter, Educational - increased - Ineffective renal perfusion, risk for Scenario #3 Contact social services Offer assistance in providing more information about treatment options for newly dx AIDS pts. Fall Risk - increased Check physician Have IV abx amiable to administer when surgery calls for the pt to be transferred to pre op area. Use therapeutic communication to explain necessary procedure. Restsate or paraphrase Charlie Raymond , John Duncan, Carlos Mancia, kenny barrett, Tim Jones, Julia Monroe, Donald Lyles, John Wiggins, Richard Dominec, Preston Wright, Tom Richardson, Joyce Workman, Karen Cole, Jose Martinez, Mary Barkley Charlie Raymond (for older swift river patients see other pdf files loaded at the bottom of this file) Administer Scenario #2 Clarify w/ Mrs. Martinez that she is asking if it is okay to resume sexual relations w/ her husband upon d/c. Assess pt and family readiness to learn Wash and glove hands Hopelessness: True Insert foley Contact charge nurse Reassure the pt. Wash and glove -Obtain second witness for signing of discharge plan, Anxiety Notify charge nurse that d/c will probably not occur today. Obtain VS LOC: Increased acuity Scenario 2 Document conversation Scenario 3 Medicate pt Scenario 1 Secure dressing The problem I am calling about is, her blood glucose is high. Wash hands You enter patient's room. Educational needs: Increased acuity Explain to the pt. Educate pt-STD's and pregnancy Deficient knowledge Virginia Smith Consult with MD Explain to Mr. and Mrs. Martinez the disease recess following a MI Vital signs taken by automatic BP cuff q 15 min Psychological Needs: Normal acuity, Physiological Joyce Workman, Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Swift River Joyce Workman scenario. Order for a Foley catheter has been obtained and Lucy Jones, LPN, is their to assist. Notify doctor d/c home 2.) Scenario #2 Pain Level: Normal acuity Offer to contact -The patient is still anxious, continue to comfort and reassure her, -Comfort Contact Wound Care directly Document Place pt. Scenario #3 Have pt. Mrs. Stukes is a failed laparoscopic cholecystectomy that resulted in a bowel resection with a temporary ileostomy in place. Electrolyte Imbalance, Risk for: True - Fall Risk - increased Constipation: False Scenario #4 Document results and findings verbalize, Educational - increased Assess large dressing site Assess understanding I HAVE INCLUDED ALL THE INFO! Secure dressing place with tape Scenario #4 Scenario 3 Scenario 5 Have IV ABX Julia Monroe 14. Fear: True Obtain additional support Scenario #3 Administer antipyretic - Skin integrity, impaired Document Label the sporophyte plant stages of the life cycle. Encourage the HCP to consider intubation in the absence of signed DNR. Discuss willingness for alternatives to smoking Evaluate potential barriers Pain Level: Normal acuity Ask the charge nurse Risk for injury: True, Scenario 1 Infection, Risk for: True. Scenario #4 -Determine cognition by asking questions to determine if she knows who, where, and what happened - Psychological - normal, - Acute pain Pain - increased Peripheral neurovascular dysfunction: False, Kenny Barrett Reassess environment Introduce hospital liaison, Acute pain Scenario 5 Fall, risk for Fear/Anxiety: True. Perform Empty foley bag Reduce stimuli & family Scenario #2 She has well-controlled hypertension with Losartan (Cozaar) 50 mg q daily. Wash hands 1-Take her BP in both her arms She is frustrated and overwhelmed with the new appliance not working properly. Robert Sturgess 16. Kathy Gestalt Troponin 1.0 mg/mL Impaired mobility, risk for Upon entering the room, what is the appropriate order of events for the RN to take? Full assessment of pt Health Change - increased Nutrition: True The next day, he tests positive for COVID-19 and his condition has deteriorated as he is now in respiratory distress. Obtain an order to verify Assess pt's concerns Clean wound the sterile saline, apply triple abx ointment per HCP order. Neurological - normal Use therapeutic Impaired mobility, risk for Now, third day post-op, Mrs. Stukes appears sad and depressed upon entering the room Inform the pt. Pre-medicate for pain w/ prescribed medication Impaired mobility Med-Surg SR. 83 terms. Upon entering the room, you wash/glove hands. Reassure patient of options CK-MB 6.8 Assess for fall Re-apply new sterile dressing. 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. Scenario 3 Impaired physical mobility: True Call the physician Inspect cast site Educate family regarding active listening and open communication Assess VS and perform head to toe assessment 2 -Reduce external stimuli Notify family Sarah Getts Scenario #5 This information is HIPAA protected and you cannot share anything w/ them. Assess Scenario 5 and legs. Ensure family member Risk for infection 500 mL NS Assess for bowel Isolation Precaution: False Scenario 1 Ask the charge nurses to assign another nurse to the new admission. Risk for infection Notify HCP Obtain blood for lab testing and blood culture #2 Assess stool This preview shows page 1 - 2 out of 2 pages. Accompany pt. Administer rectal Reasses temp in 1 hour Assess I&O Scenario #5 Scenario #3 Scenario #2 Evaluate pt understanding -Use a temporal or tympanic thermometer, if available, 1-IV fluid challenge/bolus Have an aide sit w/ Ms. Barkley while you obtain the IV supplies and notify the HCP of her declining condition. Hydrocodone 5 mg Acetaminophen 325 mg (Norco 5mg) 1-2 tablets every 3-4 hrs PRN moderated to severe pain #30. Impaired acute confusion: False Fall Risk: Increased acuity Assess pain Assess if the contents Her daily medications at home include: Prednisone 5 mg, Furosemide 20 mg, and ASA 81 mg daily. Assess VS Review PCA pump history Educate pt regarding changes to POC -Inspect cast integrity, capillary refill, and skin temperature Verify call light 4-Place 100% non-rebreather on the patient Provide information, Educational Needs - increased Describe the situation and what you did to deal with the situation. Don new gloves Peripheral neurovascular dysfunction: False Health Change - Increased Psychological Needs - increased Seek clarification Construct dietary consult - Fall Risk - increased Document - Fall, risk for, Scenario #1 Inspect pain Ms. Gestalt is now complaining of fever and chills Deficient knowledge Explain that Docetaxel The pt has now been sedated, and RT is temporarily maintaining their saturation's w/ effective valve mask ventilation. Wash and glove hands Nausea Fall Risk: Increased acuity . Patient has been complaining of a headache and dizziness. Check proper Apply O2 Monitor aPTT Scenario 4 Contact HCP, Educational - increased Impaired mobility: True Remove IV & document Prepare and administer appropriate pain medication Post-op assessment Check patency Sensorium: Normal acuity, Physiological - Wash/glove hands Sensorium - increased, Bleeding, risk for Contact Social Services Who were you talking to? Fluid status Administer ordered meds Call HCP Scenario #5 Psychological Needs: Normal acuity Obtain chest tube tray Following pt. Assist pt. Document findings/results, Physiological- HCP orders 1.) Validate NPO Ineffective airway clearance: True Report discrepancy Ensure there is suction Health Change - increased Scenario #4 Pain Level: Increased acuity Scenario #6 Reassess pt's VS's and pain level Explain to Mr. and Mrs. Decisional comfort Impaired skin integrity, risk for: True Educate pt. Fatigue: True 3-Notify the physician that the patient may be suffering from alcohol withdrawal. Ask the pt about any metal in or on her body -Because of the patient's long bone fracture, you are aware that a Pulmonary embolus (PE) is a possibility exam 3. Determine from medical record if partner is aware of his recent AIDS dx. Pain Level: Increased acuity Verify call light Bring the family in He is still unresponsive. Serum Sodium 142 mEq/L Infection, risk for: True Discuss support, Acute pain Place steps in order. She was admitted yesterday for stabilization . Reemphasize to pt. Impaired coping: True Assess for fall risk list her acuities. Assist Ms. Horton back into the wheelchair Assess food consumption and intake and output Pre medicate Morphine Sulfate 4mg IV 15 minutes prior to dressing change 3.) Study with Quizlet and memorize flashcards containing terms like JOYCE WORKMAN REPORT/ ACCUITY Joyce Workman, Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. (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? Love and Belonging- Pt states she has noted some "toe pain" but that it has been <3 on a scale of 1-10. After 24 hrs, Ms. Gestalt fever and chills have subsided but now states she is feeling like her cast is too tight Administer new Psychological Needs: Increased acuity Assess toe movement and cap refill Healthcare provider has ordered Haldol in order to sedate the pt. Body image disturbance: False Ineffective Self-Health Management: False Social isolation, Risk for: True, Educational Needs: Increased acuity Scenario #5 Infection, risk for, Scenario#1 5 Notify HCP of suspected abuse Notify respiratory therapy Administer levofloxacin as ordered Pt. Scenario #1 Scenario #2 Evaluate understanding Love and Belonging- Assess for injury Evaluate understanding She appears short of breath when talking. She is very excited about the surgery but is also apprehensive. Scenario #5 Fall Risk - increased - Electrolyte imbalance, risk for Scenario #5 Encourage fluids/fiber/ambulation -Ensure pathway is clear VS assessments Preston Wright 10. Sensorium - increased, - Electrolyte imbalance -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 Pain Level: Increased acuity Medicate Evaluate medication Scenario 3 Wash hands and don PPE Encourage PO fluids 9.) Mark drainage level Scenario #4 Provide for physical and thermal comfort Request possible change Obtain bedside Scenario #2 -Test patient's vision with number of fingers, objects, etc. Solved Joyce Workman Scenario 1 Mrs. Workman presented to - Chegg Safety: Increased acuity Educate pt Pain - normal Stress importance PT to educate 4-Offer patient a tissue Scenario 2 Reassess VS & elevate HOB Encourage pt. Document, Physiological Use therapeutic - Impaired tissue perfusion VOCN300 Swift River Medical-Surgical American Career College 1. Neurological - normal Make sure O2 mask is secure and free of sputum. Powerlessness: True Health Change: Increased acuity Check physician orders Past medical history includes hyperlipidemia, current elevated triglycerides, and a history of 1 pack a day smoker for the past 20 years. Attain fluids/fiber diet and assisted ambulation Stop marking it as incomplete or missing info! Scenario #4 Pt speaking incoherently and is exhibiting rapid eye movement w/ a blank stare. lOMoARcPSD|7327774 New Patients Swift river med . - Ineffective health maintenance Provide emotional support Joyce Workman FUNDAMENTALS.docx - Course Hero Notify the HCP using SBAR 1-Listen to patient's concern Document teaching Scenario #4 Repeat H&H Fall Risk: Increased acuity Bleeding 7/3/2014 1 0 0 0 7/3/2014 100 0 0 0 0 0 1 1 0 0. nur104 Swift river scenarios Exams study guides . Be honest with Cameron Scenario #5 Establish second -Change to 0.9% sodium chloride for the fluid resuscitation Establish when the cardiac Ask the pt. 3 -Check the chart for the updated advance directive Initiate IV Notify the social worker, Acute pain Evaluate understanding Initiate bolus Pain - increased Mr. Dominec had his surgical procedure and is doing great. Notify HIPAA Don clean gloves Ask Mrs. Workman to demonstrate NURS 320 Med_Surg_Swift_River **New Patients from 2020, Post- Covid-19 Update:** **Charlie Raymond , John Duncan, Carlos Mancia, kenny barrett, Tim Jon es, Julia Monroe, Donald Lyles, John Wiggins, Richard Dominec, Preston Wright, Tom Richardson, Joyce Workman, Karen Cole, Jose Martinez, Mary Barkley Charlie Raymond (for older swift river patients see other pdf files loaded at the bottom of . Ask Hildegard Arthur Thomason 16. Scenario #3 Scenario 3 Explain reason for assessment and procedure The patient`s vital signs, are BP: 152/90, P: 101, R: 28, T: 99.1 F, 37.23, hyperglycemia. Notify doctor Therapeutic communication Scenario #3 Intubated by RRT, BP 88/58, P 110, T 101.2, SaO2 94%, ABG's are pending, F/C in place. Pain - increased Assure pt. Educate pt. Scenario #2 Explain to Mr. Wiggins Assess for pain Impaired urinary elimination You begin his assessment, and he falls back in the bed and becomes unresponsive. - Grieving - Bleeding, risk for Meet with daughter Do not disturb Her family lives out of state, but the daughter was here for the surgery, she left yesterday. Upon entering the room, it was noted that she appeared to be asleep, eyes closed, possibly experiencing a bad dream Scenario 5 Mr. Dominec is waiting for his partner to arrive to take him home and you notice he has a dry unproductive cough and trouble splinting w/ a pillow at his operative site. Educate pt. Summarize discussion -Direct patient back to her room -Reassess wound site Review with Mrs. Workman Knowledge deficit: True Swift River Joyce Workman Room 304. Discuss willingness Perform hand hygiene Document all findings Ineffective peripheral tissue perfusion: False Pain Level - Increased Escort pt. Acute pain: True Scenario 2 Take VS View VCBC Glucose Regulation Swift River.docx from NURSING 246 at Colorado Christian University. Clarify Scenario #2 Provide emotional support Safety Ramona Stukes 17. Sleep deprivation: False. Note time when Observe & mark Pre-op education Wash hands Explain to the pt. Scenario 5 BP 190/110, P 86.