Complete neuro Initiate head-to-toe Chronic pain: False Wash and glove Take vitals Scenario 3 to explain Sensorium: Increased acuity, Educational Needs: Increased acuity Scenario 3 Therapeutic communication Contact social services Inform the pt. Scewl Swift River Nursing 100. . -Because of the patient's long bone fracture, you are aware that a Pulmonary embolus (PE) is a possibility Obtain urinary Pt. - Knowledge deficit Ms. Rails was medicated with hydrocodone 5 mg PO two hours ago and is now complaining of pain (8/10 pain scale). Joyce Workman, a 42-year-old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Social isolation, Scenario #1 Explain to the pt. If cardiac Kathy Gestalt 9. Ineffective Coping: False Provide education regarding HF Impaired Skin Integrity, Risk for: False Educate pt, - Educational Needs - increased BUN You begin his assessment, and he falls back in the bed and becomes unresponsive. Fall Risk: Increased acuity Mrs. Stukes's husband is not willing to help assist pt upon d/c w/ her stoma care for failed laparoscopic cholecystectomy. Acute Pain False Place call light and check bed for safety Joyce Workman 12. Dr. Brown gives orders to remove NG-tube set to gravity and to begin a clear liquid diet Deficient knowledge The pt continues to be combative while attempting to initiated the CPAP trial. Neurological - normal Obtain surgical Estelle Hatcher Constipation: False Risk for Infection: True Document Observe for bleeding Deficient knowledge Notify Dr if condition is abnormal Check leads Scenario #2 Notify MD for F/C hali149 . Educate pt 4-Notify anesthesia to come to the floor to evaluate the patient. Check pupils Health Change: Increased acuity Clean wound the sterile saline, apply triple abx ointment per HCP order. Place the syringe in a biohazard bag and place a pt id label on bag Pain - normal Document all findings Document Right after admission the nurse finds her walking down the hall trying to leave. She was admitted yesterday for stabilization of her glucose levels, and assist her with lifestyle modification. Administer pain meds New-patients-swift-river-med-surg-covid-new-patients-charlie-raymond Fatigue Verify call light Wash and glove hands Educate the family regarding intervention and support for Ms. Horton Ms. Rails states that she has not had a bowel movement (BM) in the past two days. Scenario #1 Dietary consult, Educational - increased Fear/Anxiety: True. Notify lead RN Failure to thrive. Discuss his understanding Anxiety False Obtain IV access -Wipe down chair with disinfectant Obtain Spanish signs and brochure Secure dressing place with tape Upon enter the room, she asks you if she will be able to drive when she gets home tomorrow. Administer pain meds VS assessment Include pt. Wash/glove hands Perform focused respiratory assessment Change to simple Inspect pain Anxiety: True Grieving: False Scenario #3 Noncompliance: True, John Duncan Acute Pain: True She has received a dose of Hydrocodone for PRN pain 20 minutes ago. You hear a scream coming from Mrs. Horton's room. Complete head-to-toe Psychological Needs: Increased acuity Have pt put on a mask Scenario #2 Sleep deprivation: False Check pedal capillary refill Deficient knowledge Explain to the pt. 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 . - Pain - increased Full assessment Safety- Pain Level: Normal acuity -Check to see availability for PRN anxiolytic medication Review labs 3 terms. Scenario 4 Document Notify housekeeping, Educational - increased Medicate Encourage Mr. Wright to include high protein snacks in his diet Ensure continuous EKG monitoring Ineffective self-health management: False Administer pain meds Scenario 2 Self-Care Deficit: False Check physician orders Check for breathing and carotid pulse Bleeding, risk for: True 3-Inform the patient that there are many successful treatment options Compromised family coping: True Scenario 3 Scenario 2 Pain Level: Increased acuity Bleeding -Explain HIPAA policy to the patient's boss Don PPE Scenario 4 Give an SBAR to hospitalist, Scenario 1 Witness daughter Scenario #2 - Anxiety Infection, risk for, Scenario #1 Scenario 4 Scenario 2 Use therapeutic communication/active listening Document findings Psychological Needs - increased Have the pt. Scenario 2 Later in morning care, Ms. Como requests o take a shower stating she feels 'dirty'. Scenario #1 Scenario 3 Fall Risk - normal -Change to 0.9% sodium chloride for the fluid resuscitation Obtain translator Scenario 3 Call RRT Start O2 100% Scenario 3 -Inform the patient that he will have plenty of time to decide, and the Provider will discuss all the options with you Marcella Como is now more talkative and shares with you that she is going to cooperate and wants to press charges against the assailant. Educate Mrs. Workman Assess leg Document Evaluate pt. Make sure O2 mask is secure and free of sputum. Scenario 4 List the nursing care order. Administer antipyretic medication Psychological Needs - increased Fall Risk: Normal acuity Audiology changes, risk for Therapeutic communication - Disturbed body image, Scenario #1 Evaluate understanding Initiate IV Reassure pt. -RRT has arrived, coordinate patient care for a stat VQ scan Hypothermia: False Skin integrity: False, Charlie Raymond Gas exchange, risk for Mr. Raymond continues to deteriorate and becomes confused. -Patient Education Establish second The patient, is a full code. Medicate Scenario #5 Request order for telemetry Scenario 1 Fall Risk: Normal acuity Assist pt Administer nausea med Scenario #4 Encourage to ambulate (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? Scenario #4 Communicate w/ the pt therapeutically Reposition HOB to semi-fowler's Document, Educational - increased Provide comfort Perform hand hygiene - Bleeding, risk for Infection, Scenario #1 Gas exchange Accompany pt to ICU and give report to receiving RN, Educational Needs: Increased acuity Do not probe further Reassess pt. Assess the pt. Apply new dressing Psychological Needs - increased Set her up Consult wound care After two hours, Mr. Dominec is alert and cooperative, nauseated and concerned about impending surgery this evening. Pt. Document results Fall, risk for Don clean gloves and removed the old dressing. Assess and document Reassess pain Provide an exercise routine Have pt. Impaired mobility: False Begin post op education for day one She has just been transported from recovery. Scenario 4 Deficient knowledge -Prepare SBAR for arriving team Encourage fluids and fiber diet