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Assess stress level Health Change: Increased acuity Take VS Just received an order to initiate 20mg of Furosemide (Lasix) IVP, BID. Document results His partner is at the bedside asking, "How much longer will he have to wait until taken to surgery?" Notify doctor (for possible removal) Orient patient to utensils and location of food on tray Scenario 2 Contact respiratory therapy Reassess pt. Take VS now and Q4 hrs Initiate bolus Before entering Carlos Mancia room to administer his antipyretic medication for his recent temp of 101.2 Scenario 5 Linda Yu, was admitted to your unit after surgery on her left hip due to a fall. Notify family, - Educational Needs - increased Educate pt. Offer assistance Follow HIPAA Swift River Linda Pittmon scenario - BSN 366 - Studocu Sleep deprivation: False Insert Foley catheter according to hospital recommended guidelines, to ensure sterility of catheter. Place the syringe Obtain a sitter/UAP - Noncompliance Ineffective health maintenance Obtain translator Inform & educate spouse -Wound Cultures Scenario 4 Scenario #5 Discuss with HCP Don 2nd set of clean gloves to provide stump care. impaired comfort Scenario 5 Fundamentals swift river Flashcards | Quizlet Reasses temp in 1 hour Establish and IV line Follow HIPPA protocol - Constipation, risk for Assure pt. Scenario 3 Wash/glove hands Provide initial report and assist RRT Reduce stimuli in the pt room Summarize Ensure surgical consents Document and provide copy for Mr. Dominec to share w/ his follow up appointment tomorrow. Reassure the pt. Assess pt's blood glucose Health Change: Increased acuity Review current Scenario 2 Give tylenol Mr. Martinez lab work comes back post-stent placement Sleep deprivation: False. NG tube to LIS Obtain blood (culture #1) Scenario #3 Gather supplies needed for dressing change Notify doctor -Note that the family member support has been invaluable, and encourage her to stay. Scenario 4 Administer ABX & start morphine Document procedure Impaired urinary elimination: False -Perfusion Orient pt. Insert new IV Fall Risk - increased LOC - normal Multiple burn injuries have overwhelmed the local hospitals. Ensure cardio pads Electrolyte imbalance, risk for: True Inspect pt's abdomen chp 19 managerial accounting connect. 1-Do not give out any information without consent from the patient Psychological Needs - increased Scenario 2 Bleeding Risk: False 1-Obtain a new IV site Dr. Brown gives orders to remove NG-tube set to gravity and to begin a clear liquid diet - Neurological - increased Notify lead RN/ DR of new circumstances Offer masks to visitors Attempt to orient to person, place and time Perfusion, risk for Ask pt. -Explain HIPAA policy to the patient's boss Infection, Risk for: True. Maintain strict I&O's Ask the pt. Seek clarification Impaired physical mobility: True Scenario #3 4-Notify anesthesia to come to the floor to evaluate the patient. Practice using IS Request time Administer protocol antidirrheal medication Charge the monitor Refer caller to contact health department Acute Pain: True Initiate medication -Observe the degree of chest wall movement while counting the rate and palpate the chest wall excursion Bleeding, risk for: False Document teaching Re-assess BP and pulse. Notify lead RN/Dr. - Infection, risk for, Scenario #1 Upon entering the room, what is the appropriate order of events for the RN to take? When help arrives Impaired mobility, risk for Scenario 3 Pain Level: Normal acuity Document Scenario #4 Take VS Scenario 4 Scenario #2 Request repeat potassium lab Explain how surgery Scenario 5 - Electrolyte imbalance, risk for The nurse has another high acuity admission that has just arrived from the ER. Her HbA1C is. You enter patient's room. Scenario 5 Fall Risk: Normal acuity Macro Final - Quiz 4. Describe to pt. Ensure no one in the room is touching the pt or the bed and cardiovert She was admitted yesterday for stabilization . Ms. Horton hears the jackhammer and then screams and dives to the floor. Collect stool Document, Educational - increased Have secretary Scenario #4 Assess pain and rhythm Q15 minutes I am concerned about keto-acidosis and, I am calling about Joyce Workman. Document They wanted to know and pressure you for the information. Use therapeutic communication/Active Listening Request the uncle come Change IV fluids to 75ml/hr 8.) Use therapeutic communication/Active Listening Initiate incident report, Acute pain Evaluate potential barriers The HCP prescribed the following orders, place in implementation sequence: Explain the necessary procedure -Inform the patient that we cannot honor her current advance directive Explain that Radium-223 Imbalanced Fluid Volume, Risk for True - Physical mobility, impaired Scenario 2 Scenario 1 Use therapeutic Scenario 5 Document teaching Explain to daughter Ineffective breathing pattern: True Notify RRT Scenario #2 Attempt de-escalation strategies Impaired mobility, risk for Explain to the pt. Acknowledge Have pt put on a mask Therapeutic communication Begin list of medications and time/dose given. Grieving Deficient Fluid Volume, Risk for: True Infection, risk for, Scenario #1 Anxiety: True Scenario #5 Contact family Ask if the pt. Check patency Introduce yourself 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 . 3-Supplement Oxygen