Started on Atenolol 50mg, 1x/day. Continue to observe Fall, risk for: True Adjust crutches Check proper positioning Ms. Rails shares with you her fear of being discharged home to an abusive husband. 4-I suggest that you start the patient on an insulin glucose infusion with a blood glucose check q hourly. Psychological Needs - increased Health Change - increased Assis pt. Rape-trauma syndrome Assessment of bowel PT to educate Administer pain medications Give 1mg atropine - Anxiety Contact dietary consult Document Consult with MD Administer pain meds Don clean gloves and removed the old dressing. Obtain chest tube tray Scenario #5 Physiology- Impaired comfort Secure sitter to stay w/ Ms. Barkley after the insertion of the new IV. Wash/glove Call respiratory therapy Mrs. Hatcher appears restless, diaphoretic and calls the nurse for help. She is super morbidly obese with a BMI of 52, Ht, 5'3", Wt, 293lbs. Report current urinary output quantify per hour and color of urine Provide emotional Scenario 3 Reassess pt. Give ASA Deficient knowledge Anxiety: True This information is HIPAA protected and you cannot share anything w/ them. Notify Cath lab The nurse has Ms. Horton in the wheelchair ready to be taken down to the lobby by the UAP. Reassure pt. Asses Mr. Wright's willingness Adjust crutches Joyce Workman, Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Document in the pt record Assist the pt back to bed Inform healthcare provider Before entering Carlos Mancia room to administer his antipyretic medication for his recent temp of 101.2 Educate pt. Document teaching Health Change: Increased acuity She has been documented as being obese, new-onset hypertension, polyuria, and a rash on her abdomen. 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Complete full assessment Scenario 5 - Physical mobility, impaired Bleeding, Risk for: True Electrolyte Imbalance, Risk for: True Check cranial nerves Discuss with HCP Visual assess Connect pt to cardiac monitor, assess vital signs Ask pt to explain to you what procedure she was expecting to have this morning. Observe closely first hour Full assessment Vitals? Perform focused respiratory assessment Risk for Infection: True Check wound sites HTN was undiagnosed and was. She has been documented as being obese, new-onset hypertension, polyuria, and a rash on her abdomen. Guide her back to her room while teaching her that her isolation is to protect others including her family. Health Change: Increased acuity Health Change: Increased acuity Sensorium - normal, Acute pain Obtaintelemetry Scenario 1 Record I/O VS & head-to-toe Notify family as to when they may come and visit, Educational Needs: Increased acuity Don gloves Psychological Needs: Normal acuity Scenario 1 Sexuality, Scenario #1 Scenario 1 Acute confusion Infection, Risk for: True. Verify call light Scenario 2 - Sensorium - normal, - Chronic pain Use therapeutic Document findings Inspect site Nausea: False Perform neuro assess Encourage Mr. Dominec Joyce Workman 14. Maintain strice Assess pt's ABCs Check the foley Follow HIPAA Check VS Scenario 3 Inspect pain Scenario 3 Talk with Mr. Jones His . Pain - normal - Pain - increased Scenario #3 Ensure continuous Use therapeutic communication/ active listening Bleeding, risk for: False Anxiety Assist with airway Nutrition Scenario #2 Measure wound size at greatest length, width and depth using a disposable paper tape measure. Provide a few chairs if possible for her family to also be comfortable Ensure foley is draining Notify doctor Notify lead RN and Dr. Explore new ways Assess for the abrupt cessation of pain Scenario #5 Electrolyte Imbalance: False change diet to HH 6.) -Notify HCP and nursing supervisor Scenario 5 Contact family Grieving: True 6 terms. a urinal Scenario #2 Scenario #5 Educate Jody's parents Educate pt Notify the social worker, Acute pain Document education, Educational - increased Call RRT, rapidly prioritize the following NrsSR22. to remain Assess pt. Scenario 4 3-Her current vital signs are BP: 152/90, P: 101, R: 28, T: 99.1 F, SpO2: 94%, she is alert and oriented to person, place, and time. Apply new dressing Monitor for adverse effects Therapeutic Communication Inform his partner Scenario 5 Impaired home maintenance management r/t client or family: False Serum Potassium Joyce Workman, Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Neurological: Normal acuity Scenario 4 Scenario 1 Ask the pt if she has had the procedures previously - Risk for physical injury - Neurological - normal Wash hands Give pt. Scenario 2 Report discrepancy Joyce Workman 12. Assess pain 5-Take an axillary temperature with the blue electronic thermometer Ask pt. Explain to daughter & VS, Educational - increased Assessment of bowel movement on O2 Secure dressing place with tape You determine to apply the restraint now. Psychological Needs: Increased acuity, Educational Needs: Increased acuity She is also anxious as a result of recent surgery. Call for CODE-blue Repeat neuro Fall Risk - normal Obtain assistance Promote open communication between mr. and Mrs. Martinez She was asymptomatic upon arrival. Educate pt. Pain - increased Ineffective coping: True Ensure informed consent for procedures is signed Deficient knowledge Assure pt. Obtain IV access and draw initial labs -Provide emotional support for the patient`s husband. Scenario 2 he chooses to go home and see the dr tomorrow in his office. Scenario #3 Inform pt. Orient pt. Ms. Gestalt is now complaining of fever and chills Listen to patient concerns Assess pain Deficient knowledge: False Discuss w/ pt identified home health needs Alert Mr. Wright's case manager of concerns of home environment. Anxiety: True Sensorium - normal, - Acute pain Contact nursing supervisor Ask the patient when the advance directive was last updated Psychological Needs: Increased acuity Scenario #2 Noncompliance, Scenario #1 Bleeding: False Create sterile field w/ foley kit on the bedside table and don sterile gloves. Psychological Needs: Normal acuity Scenario 3 Educate pt Attempt deescalation Risk for injury at home, Scenario #1 Health Change: Increased acuity Impaired Gas exchange: False Marcella Como is now more talkative and shares with you that she is going to cooperate and wants to press charges against the assailant. Fall Risk - increased Safety- Report suspicion of abuse to adult protective services Scenario #5 Imbalance nutrition: True Use therapeutic communication/active listening -Blood Cultures Instruct pt. Pain - normal Request sitter/family member to bedside Explain how surgery Notify HCP - Pain - increased Sensorium: Normal acuity, Physiological- Social isolation: True, Marcella Como - Pain - normal Take initial VS Assist with applying -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 Reassess VS and chest pain 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. 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The wound has been sutured and is not and open wound/stump. He also states he is feeling weak Mr. Dominec decides he does not want to see the ID MD about his new cough. Administer pain meds Request CNA to remain w/ pt If pt. Provide comfort Encourage Mr. Wright to include high protein snacks in his diet Obtain an order - LOC - normal Constipation: False Administer nebulizer Encourage fluids Risk for post traumatic stress syndrome Fear: True Contact dietary Scenario 5 Donald Lyles, 52-year old male, was admitted yesterday evening for stabilization of his uncontrolled type II diabetes. Check the blood Infection, risk for, Scenario #1 Procedure is cxld for the day and rescheduled later allowing for new consent. Mr. Richardson is now pain free and questioning why he is plagued w/ recurring urinary stones. Initiate secondary Impaired Comfort: True She is 85 years old and has a history of osteoarthritis and cataracts. Establish an IV Scenario #3 - Fall Risk - increased Scenario 1 Scenario 1 Health Change: Increased acuity The HCP prescribed the following orders, place in implementation sequence: Teach pt. Legal in Canada since June 2016 Implications? Wash hands Disturbed sleep pattern: False Richard Dominec Impaired mobility Consult wound care Scenario #3 Call for triple lumen Notify HCP Allow family She presses the call light w/ questions about who her RN will be and her NG-tube. Therapeutic communication Impaired gas exchange: True Use therapeutic communication/active listening They were also concerned about the next pt going into that room and the use of the lavatory. Explain to Mrs. Workman Fall Risk: Increased acuity Impaired comfort Evaluate pt understanding I suggest 10 units of regular. Assess and document Nutrition You are entering the room for the first time. Scenario #4 mary_heath32. 3-Notify the physician that the patient may be suffering from alcohol withdrawal. Fall, risk for Nutrition: True Encourage fluids/fiber/ambulation Give tylenol Electrolyte imbalance, risk for: True Pt Kenny Barrett is nauseated and complains of dizziness when he sits up. Inform pt. Educate family regarding active listening and open communication Complete initial Encourage pt. -Explain to Mrs. Barkley that you are going to change her linens Prepare to initiate cardioversion. Have an aide sit w/ Ms. Barkley while you obtain the IV supplies and notify the HCP of her declining condition. Self-care deficit Obtain an order to insert a Foley catheter Encourage aggressive IS Initiate medication Decreased cardiac/perfusion: False Post-op assessment Educate pt. Call HCP for change in health status and receive orders for anxiety medication Discuss lifestyle changes Notify HCP Decisional conflict: False - Fall, risk for Start IV Using therapeutic Pain, Acute: True Remain with pt. You discuss this cough Seek clarification Document Infection, risk for, Scenario#1 Ensure no one Tell me where you are Pain Level: Normal acuity Assess leg Orient pt. Remove NG Neurological - normal, Chronic pain Scenario 2 Fall Risk: Increased acuity Impaired Comfort: True Safety- Elevate stump, - Educational - increased Notify Dr. of change the PCT is requesting to be relieved as the pt keeps pulling at the PCT's mask to see who she is. Chronic Pain: False Ms. Rails states that she has not had a bowel movement (BM) in the past two days. 37. Kenny Barrett Pain - increased Encourage fluids and fiber diet Health Change: Increased acuity The patient`s vital signs are BP: 152/90, P: 101, R: 28, T: 99.1 F, 37.23 C, hyperglycemia. Obtain IV access Disturbed personal identity: True Ask pt. Assess VS and perform head to toe assessment Don appropriate PPE 1-Obtain a new IV site Safety Scenario 3 Educate Ms. Horton that paroxetine (Paxil) is to be taken as ordered Prepare the patient for possible intubation - Impaired comfort -Assess radial and apical pulse for 60 seconds Safety Begin list of medications and time/dose given. Teach pt about safety when getting out of bed Page surgeon STAT Health Change - increased Concepts of Nursing IV 80% (5) -Mobility Document consults, Educational - increased Obtain bear hugger Vital signs are to be taken BID and it is now time Complete incident report, Acute pain Assess VS diagnosis of type II diabetes. Scenario #2 Set up sterile 2-hrs later, Mr. Duncan is asked how frequent his stools have been today. Use therapeutic Call for crash cart Hold next dose -Prepare SBAR for arriving team Fall, Risk for: True. Fall Risk - increased Document Disturbed body image: False Inform & educate spouse Encourage Mr. Dominec to discuss w/ his partner his best tx options. Administer antiemetic Scenario 3 Scenario 5 -Tell the patient that dressing must be changed, 1-Put a mask on yourself Scenario #5 Health Change: Increased acuity Talk to daughter Assess pt's concerns Esteem- Rank as most concerning for labs Document all findings Continue medicating Provide another Determine if the pt. Impaired mobility The patient`s vital signs, are BP: 152/90, P: 101, R: 28, T: 99.1 F, 37.23, hyperglycemia. Neurological - normal Impaired skin integrity, risk for Reassess VS & obtain UA Scenario 2 Scenario 4 You return to the break room on your floor. to avoid Deficient Fluid Volume, Risk for: True Use therapeutic - Infection, risk for, Scenario #1 Evaluate caller understanding Scenario #3 Scenario #3 Anxiety: False Scenario 5 We need to stop the bleeding Scenario 2 Notify infection control nurse Documentation They wanted to know and pressure you for the information. Anxiety: True Assess large dressing site Pt. Ineffective Airway Clearance: False 88 y/o female Acute Pain: True She is disoriented and believes the nursing staff is trying to kill her. I am concerned about keto-acidosis and, I am calling about Joyce Workman. Explain to the pt. Impaired skin integrity: False Scenario #2 Deficient diversional activity: False Don clean gloves to remove old dressing -Assess level of help needed Scenario #4 - Psychological Needs - increased, - Acute pain Ensure family member The sister of Mr. Mancia calls from home to speak w/ you. Explain the TX immediately. Deficient knowledge Allow expression privacy Prepare and administer Talk w/ her stating surgery is over and she did great Educate pt-STD's and pregnancy -Assist patient in performing hand hygiene Obtain 16 gauge angiocath Read PT report Verify if discharge, Impaired comfort Scenario #3 Scenario 4 Contact isolation Infection, risk for: False Remind pt. She has active bowel sounds Acute confusion: False Verify with blood bank Hand hygiene Explain to pt. Educate pt. Apply O2 Scenario 4 Explain to her family Measure nose to ear Scenario #5 Scenario #2 Neurological - normal 4-Observe the complete respiratory cycle Scenario #4 Full assessment Ask Hildegard Fall, Risk for: True Pt. Contact charge nurse Provide pt. teaching Obtain blood for lab testing and blood culture #2 Evaluate understanding Fall, risk for Use therapeutic She was admitted yesterday for stabilization of her glucose levels, and assist her with lifestyle modification. Impaired skin integrity, risk for: True Discuss the policy Document procedure Assess documented pain Contact HCP if pt status does not improve Clean wound the sterile saline, apply triple abx ointment per HCP order. Provide pt. Scenario 2 Tom Richardson Assist with insertion Psychological Needs - increased Request order for telemetry Ms. Hatcher is second day post-op and has a NG tube set to gravity drainage only. Acute Pain: True You hear a scream coming from Mrs. Horton's room. 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 . Impaired comfort Establish second Notify Dr if condition is abnormal Psychological Needs - normal, Acute pain Obtain labs Verify call light/ bed safety precautions Attain fluids/fiber diet and assisted ambulation Wash/glove hands Self-care deficit: True If gastric reflux Offer masks to visitors Risk for decreased cardiac output: False Transport Mr. Burgandy Vital sign assessment Use therapeutic Put on gown and mask Explain the necessary procedure Change to simple Call security Spiritual distress: False Scenario #4 Pain - normal Reassess VS Evaluate understanding Encourage Mr. Wright Scenario 5 Do not disturb Impaired home maintenance mgmg r/t client or family: False Scenario #5 Explain in lay . 5 Notify HCP of suspected abuse 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. to explain Mr. Lyles calls you via the call light. She, states she leads a sedentary lifestyle as a bank officer. Safety: Increased acuity, Physiological- Assess respiratory status by observation Health Change - increased Social isolation, Scenario #1 Fall Risk - normal Educate pt. BUN - Drug therapy, Scenario #1 Reposition HOB to semi-fowler's Pt. Start studying swift river med surg. Explain rationales Safety: Increased acuity Peripheral neurovascular dysfunction: True. Impaired mobility Fall Risk: Increased acuity Assess for fall Complete full assessment . jessdevan. Full assessment Scenario #2 Squeeze the contents . She is super morbidly obese with a BMI of 52, Ht, 5'3", Wt, 293lbs.

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