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Gown and mask Scenario 4 Hep-Lock in place left AC. Assist physician in physical exam of patient Surrounding skin: Moist/Intact Red/Erythema Irritation Heterotrophs include (1) autotrophs, saprophytes, and herbivores (2) omnivores, carnivores, and autotrophs (3) saprophytes, herbivores, and carnivores (4) herbivores, autotrophs, and omnivores. Love and belonging Lithia Monson, 93 years old, c/o head injury, r/o subdural hematoma. Taking HIV Meds prophylaxis. He insists that he is not hungry and refuses assistance with his meal. Scenario 5 -Call security for assistance and compliance officer Gait: ______________________________, Skin Integrity Assessment Patient and family upset regarding dx. All our products can be personalised to the highest standards to carry your message or logo. -If gastric reflux is suspected administer PRN antacids (GI cocktail) Needs frequent reminding due to determination to do things herself without assistance. Noncompliance True. Deficient Knowledge True Tom Richardson, 46yr-old. No Known allergies (NKA). Allow family to remain Palliative care. Scenario 3 Educational Needs Increased acuity Pupils: PERRLA Size: R: mm L: _mm Unequal Sluggish Non-reactive IV maintenance fluids with D5 1/2 NS with 20 KCL @ 125ml/hr in left forearm. You enter his room and recognize that Mr. Thomason appears to be talking to himself and appears confused. Notify doctor Mr. Mancia's vital signs upon assessment are Temp 101.2, P 94, RR 20, BP 122/82, SaO2-91%. Insertion Site: Dry/Intact Redness/Erythema Drainage Tenderness Maceration Scenario 5 Compromised Family Coping False -Reinforce the risk if patient has not been NPO and ask the patient when the last time they ate. Mr. Gonzalez's repeat troponin was negative and no significant elevation in his other enzymes. Scenario 5 Mr. Duncan's wife meets you in hall asking what she could bring her husband to eat from home. -Medicate for pain Scenario 3 Ineffective Self-Health Management True D/C plan- decrease pain and restore normal gait. The patient is awake alert and oriented. The Swift River is one of the most unique and popular trout fishing destinations in Massachusetts, yet the dynamics of this exceptional fishery have not been well understood. Students also viewed Culture Concept notebook Development concept notebook Elimination concept notebook Gas Exchange concept notebook However, he quit three years ago when he remarried; he and his wife have a nine-month-old baby. No known allergies. Encourage fluids/fiber/ambulation Senario 4 Multiple abrasions, bruising Head, chest, and inner thigh. Apply nasal cannula Safety- He has partial thickness burns to his left arm and the left side of his face. Provide comfort and pain measures school system of the host country and may not know how to choose the programme, Question 34 Correct Mark 100 out of 100 Flag question Question text hr tag, efefefefefefefefefefefefefefefefefefefefefefefefefefefefefefefefefefefefefefefef, arbitrary parameters a b will be a complete solution of 38 The main problem then, Reduces costs of providing on site office space To individual Makes more time, METHYLXANTHINE DRUGS-Chemistry FinalsExam PrepNotes.docx, 237 Mitzel Corporation has provided its contribution format income statement for, looks like a lack of focus B In short what is stimulating to one person may be, MAN4162 - Verbal and Nonverbal Communication COPY.docx, Recall that in the Black Scholes model the stock price follows the SDE dS t S, make SOAPE and SBAR Ramona Stukes Room301 Ramona Stukes,69 yr-old, third day post-op cholecystectomy. Disoriented, confused = 4 3Check surgical consent for correct procedure and make sure operative site is marked. Pain: No Yes: Location: ______________________ Acute Chronic Constant Intermittent -Verify that discharge orders have been written, provide discharge instructions, and in inform provider about the chest pain. Encourage to ambulate with assistance to void if needed Scenario 5 His past symptoms for three months have been that he noticed a slight hoarseness in speaking, a slight dry cough not related to a cold, and upon examination had a "pea-size lump on the center of his neck". Scenario 2 Nausea False Vital sign Temp 98.4, BP 136/78, P 72, RR 20, SaO2 97%. You observe Ms. Getts being assisted by another nurse who is being blatantly rude and disrespectful to her. Sensorium Increased acuit, Physiological What order are you providing the information to the receiving nurse? Document results Diet as tolerated. RUE: ______________ LUE: _____________ -Set-up for stat portable chest x-ray Bleeding, Risk for True Administer antiemetic medication Scenario 4 Opening Title Production company Cast and crew Genre J A N U A R Y 2: The Killing of John Lennon: IFC First Take: Andrew Piddington (director/screenplay); Jonas Ball, Krisha Fairchild, Gunter Stern, Gail Kay Bell, Mie Omori, Robert C. Kirk: Crime, Drama: 4: One Missed Call: Warner Bros. Pictures / Alcon Entertainment / Kadokawa Pictures: Eric Valette (director); Andrew Klavan (screenplay . Procedure is canceled for the day and rescheduled later allowing for new consent. His CP is 7/10 and his BP is 165/96, P 92, R 18, SaO2 98 on 2L NC. Verify call light/bed safety precautions Education of Foley Cath Procedure Senario 5 Skin warm and dry, daily dressing changes, T-tube without drainage. Remain with Patient, Sarah Getts, 77 yr-old, Dx- Chronic Renal Failure, admitted with hyperkalemia (5.9, Eq/L)/hyponatremia (128mEq/L). 3. Apical/Radial Pulse Deficit: No Yes Murmur Valve Click Scenario 1 Filmotka filmu Najvyia ponuka (2013). Esteem Scenario 2 Tube Feeding: Type:_________________________ Amount/Rate: ________________________ Bolus/Infusion Awaiting diagnostic labs. Acute pain: True Several hours later, Mr. Duncan is now complaining of nausea. Senario 2 Talk with her stating surgery is over and she did great. Elevate head of bed -Ensure bed is in lowest position, and rails are in place The lesion was identified as Kaposi's Sarcoma. -Tell the patient that they are being admitted to r/o any cardiac issues Sleep Deprivation False Mr. Gonzalez has returned from his EGD and is still sleeping from the sedation. Deficient Diversional Activity False Scenario 5 Deficient knowledge: True Pulse Administer pain medications After washing and gloving hands, you then identify yourself and the patient, Ann Rails. Skin Integrity: Intact No, describe below, Location Type Size Wound bed Drainage Skin warm and dry, all vital signs in WNL Scenario 5 Infection, Risk for True The patient tells the nurse that yesterday he was, "concerned about having an erection, and now they want to cut off my testicels". 2Provide comfort in pre-surgical room Mr. Dominec. Evaluate understanding Following isolation precautions, you notice several family members are by his bedside and none of them are wearing face masks as requested by sign on door. Mr. Sturgess does not have a living will or durable power of care completed. Scenario 1 You arrive in room to find Ms. Monson talking to herself. Refer call to contact health department When you arrive to room 4, you are told to assume the care for the patient and get ready to transport them to the floor ASAP. Nausea: False Vital assessment ADA diet, intake 25%. Evaluate outcome of dietary plan He replies, "six times in the past four hours". He also has metal fragments on his left side on his leg arm and torso. Shock False He is complaining of pain in his left arm, and pain in his left chest when he tries to take a deep breath. Visual assess Robert Strurgess Chronic Pain True Scenario 3 Safety Acute Pain True Impaired Home Maintenance Management r/t Client or Family False Scenario 1 Release restraints/full range of motion This will treat any cancer that may have metastasized to the bone. Call Rapid Response protocol initiated Reasses temp in 1 hour. Scenario 1 Pain Level Increased acuity Grieving: False Combien gagne t il d argent ? Scenario 5 His overall health is good, and he has known he has been HIV positive for the past five years. -Advise patient not to get up and walk on his own SANE nurse to make second visit today. Radiofrequency ablation may be recommended after endoscopic resection. Scenario 4 Elevate Extremity Upon assessment, you determined that she is confused to person, time, and place but is easily directable. -Discuss effectiveness of sitter Extends abnormally = 2 Start secondary large bore IV line Neuro WNL alert and cooperative. Peripheral Neurovascular Dysfunction False It is determined that Mr. Sturgess could achieve better pain control w/ a PCA pump -Reorient Patient to person, place, & time Impaired Mobility True LUE: Non-pitting Pitting ___+ Senario 3 Verbal command = 3 Failure to Thrive True. Gastrointestinal Assessment You now arrive in the recovery unit one hour post-surgery and you are told that the surgery went well. Mr. Greer has returned from the radiology where a CT scan was done after his fall and while no injuries were noted there were some suspicious areas noted making concern that the cancer may have spread to the bone. Fall, risk for: True -Offer nutrition and/ or toileting Neuro WNL alert and cooperative. A few hours after speaking with the sitter about the patient needing complete observation, you notice the sitter outside of the room talking on the phone. Fall, risk for True Full assessment Family at beside. Mr. Gonzales H/H is 12.7/38. Excess Fluid Volume, Risk for False Educate patient Tunneled, site _______________ Implanted port, accessed _____________________ An abc-phase-sequence three-phase balanced wye-connected source supplies power to a balanced wye-connected load. Scenario 3 Tibial: _____ + Bilateral Other: ______________ Generalized: Pedal: ______ + Bilateral Other: ____________ Sacrum: Non-pitting Pitting ___ +. ASA is held but morphine 4 mg was given after his GI cocktail. -Contact HCP to determine when they are available to speak with the patient Safety Health Change Increased acuity Document results His left humerus is fractured and splinted. Acute Confusion True Mr. Sturgess is uncomfortable with experiencing urinary frequency that keeps him from resting. Wash and glove hands Wash and glove hands Scenario 4 Upon entering the room, the patient appears to be trying to get out of bed The charge nurse tells the nurse to take Mr. Burgundy to the floor, because his room is now ready. A new graduate nurse receives a call from the hospital telling them to report to the ER immediately for a disaster. -Reassess patients' vital signs, and place on q5 minutes continuous monitoring 0800 1200 Senario 5 Amount: _______ You call his doctor to inform him the family has arrived. The patient will be discharged today, and he will be ordering new prescriptions. Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. Safety Fall Risk Increased acuity Inspect cast site Sensorium: Normal acuity, Bleeding, risk for: False : an American History, EMT Basic Final Exam Study Guide - Google Docs, Philippine Politics and Governance W1 _ Grade 11/12 Modules SY. Verify call Light/bed safety precautions Esteem Scenario 5 Mrs. Smith shares with you that even though she signed the operative consent she was not sure if this was the right surgical procedure for her. Vital signs -Temp 98.6, BP 114/62, P 100, RR 20, SaO2 94%. Hopelessness: True Scenario 4 -Obtain chest tube tray and set-up pleurovac Cardiovascular has pacer with rate of 82bpm on demand. Color:__________ Apply restraint Stools are decreasing but patient remains very weak. Psychological Needs Normal acuity -Complete neuro checks as ordered Document results. -Restart the IV and draw CBC Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. Mr. Burgundy now has his cameraman filming in the ED and is attempting to do a live report. Scenario 4 Pain Level Increased acuity Love and belonging- Clinical 2. Spanish interpreter available at extension 61178. Knowledge Deficit True Awaiting transport. They feel that you should share with them if he was a "real AIDS" patient or not. Fall Risk: Increased acuity Senario 5 He is having some difficulty hearing and complains of ringing in his ears. Flexes abnormally = 3 Senario 2 Validate NPO Status Insertion site: Dry/Intact Redness Tenderness/Pain Warmth Coolness Swelling Drainage Ann Rails Waist belt restraint PRN; family sitter at bedside, assist with bath. 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Scenario 5 Administer antipyretic medication Fall Risk Increased acuity Fear True Document findings/results, Ann Rails, 38 years old, c/o back pain, non-significant past medical history. Too bad the cruise area was a very unatractive part of the River Elbe. Skin warm and, dry, all vital signs in WNL except 115 pulse, which is normal for him. The surgeon has suggested Androgen-deprivation therapy (ADT) with surgical castration (orchiectomy). Bleeding, Risk for False How was this Ms. Getts is now complaining of sudden sharp, substernal chest pain, very short of breath and is profusely diaphoretic. Richard Dominec, A 47-year-old married father of three children has been admitted for an emergent appendectomy in the evening as soon as there is space available in the OR. Blood Pressure, 7a-7p Total: 7p-7a Total: John Duncan, 56yr-old male, Dx- Gastroenteritis, returned yesterday from Cancun, c/o intractable diarrhea, weak, pale, and refusing to eat. Dr. Sangerstien, Viola Cumble, 92yr-old, second day post-op hip repair, Allergic to Penicillin. Demerol 25mg SIVP for pain, patient reports 7/10 on pain scale. Rapid Response team arrived including anesthesia. , a 58-year-old male patient presents to the ER CO CP 10/10. Hopelessness False. Impaired Mobility, Risk for True They would also like to start Radium-223. Stat lithotripsy treatment ordered. Wash and glove hands Ineffective Renal Perfusion, Risk for True Powerlessness: True, Scenario 1 Decisional Conflict False The patient asks the nurse to explain about these medications and why they are in such a hurry. Scenario 4 Verify call light/bed safety precautions Remain with patient Bleeding, Risk for: True Peripheral Neurovascular Dysfunction: False No known allergies (NKA). Home; Our Focus; Our Legacy; Our Partners; Our People; Our Fellows; Our Investments Why is cysteine such an important amino acid for defining the tertiary structure of some proteins? View Swift River Reflection Questions (1).docx from NRSG 4412 at South College. PT to educate patient Vital signs Temp 99.4, BP 106/72, P 96, RR 20, SaO2 91%. Sleep Deprivation False. Verify call light/bed safety precautions NPO with small amount of ice chips only. Scenario 5 Scenario 3 You also notice the patient is more difficult to orient. -Document and contact nursing supervisor/Charge nurse Scenario 4 -Reapply the NC that he was admitted with at 2L It is unclear if he lost consciousness. This information is HIPAA protected and you cannot share anything with them. Mr. Dominec had his surgical procedure and is doing great. Pain = 2 Bleeding: True Administer antipyretic medication He has not had his BP medication today. Health Change Increased acuity Tubes: None Salem Sump Nasoduodenal PEG J-Tube pH: ______ Pain affecting: N/A Sleep Activity Exercise Relationships Appetite Concentration Remind staff that Universal Precautions are practiced at this hospital for all patients regardless of known infectious diseases. Assess intake and output and possible reasoning Scenario 5 Senario 3 Remind the nursing staff that the patient is NPO. Scenario 3 Description: Sharp Stabbing Throbbing Aching Cramping Other: Skin warm and dry, all vital signs in WNL except 115 pulse, which is normal for him. Dr. Altace, Physiological- Take vital signs before leaving the hospital again. No Known allergies (NKA). Constipation False She shares concern about patient's wife who is now coughing and having night sweats. The client is onDemerol 25mgSlow Intravenous Push (SIVP) for pain. -Perform admission assessment Acute Confusion False Full assessment including both lying/standing Regardez le Salaire Mensuel de Ubah Kalimat Efektif Online en temps rel. ExplanationAnxiety/ fear True You notify the charge nurse that you have never taken part in inserting a chest tube. Acute Pain True He has been readmitted for a red spot on his sacrum of 1 cm and a 2 cm blister on his right heel. The bed arrives tomorrow. Acute Pain True She has arrived in pre-op and about to have surgery this morning. Reapply restraints Failure to Thrive True. No Known allergies (NKA). Electrolyte Imbalance True Failure to Thrive False. Scenario 3 Palliative care. LOC Normal acuity Your responsibilities are: Scenario 1 Scenario 3 Reorient Patient to person, place, & time Explain reason for assessment and procedure Evaluation patient after consult Safety Scenario 3 His difficulty voiding finally motivated him to seek care. Chronic Pain False Suprapubic Insertion site: WNL S/S Infection : ____________________ Document results Scenario 2 Hep-Lock in place left AC. Scenario 1 Regardez le Salaire Mensuel de New King James Bible Download For Windows 7 en temps rel. Discuss his understanding about the plan of care. After 24 hours, Ms. Gestalt fever and chills have subsided but now states she is feeling like her cast is too tight. It is now third day post-op, the order is for Ms. Cumble to stand by bedside on both legs for 5 minutes, three times a day. Combien gagne t il d argent ? Auscultate peripheral pulses and ROM. Full assessment of patient. Deficient knowledge: True Scenario 2 Expresses fatigue, fear, concern, and desire for recovery. Health Change Increased acuity -Notify HCP of fall, complete incident report The cancer was more advanced than they previously had thought so inguinal lymph nodes were removed. No Known allergies (NKA). -Ensure patient privacy and call for help and assist patient to bed once help arrives Grieving False -Explain to Mr. Burgundy that space in the ED is allocated based off of patient need Vital signs -Temp 98.4,BP 178/105, P 112, RR 28, SaO2 94%; Neuro- WNL's. Since the finding was low-grade dysplasia and is considered the early stage of precancerous changes, the gastroenterologist recommends another endoscopy in six months, with additional follow-up every six to 12 months. Skin warm and dry, all vital signs in WNL except 115 pulse, which is normal for him. Assessment of bowel movement Scenario 1 Bleeding, Risk for True -Give NS liter bolus Non-significant past medical history. Scenario 4 Evaluate understanding Fall Risk Increased acuity IV Assessment/ N/A Wash and glove hands Kathy Gestalt Ms. Cumble states that she has not had a BM for three days. Document Procedure Abdomen: Flat Rounded Scaphoid Distended Palpation: Soft Taut Rigid Respirations Oral Care Connect telemetry Increased fall risk. 156 terms. Mr. Sturgess is recently diagnosed with metastatic cancer of colon and he and his family have chosen only palliative care. 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 with a pillow at his operative site. Mr. Mancia is non-English speaking patient and is fearful of being discovered as an illegal immigrant. Safety- Educate patient regarding patient care The provider advises the Nurse to draw a stat CBC, give a liter bolus of NS, and repeat CBC. Some hair on the left side of his head has been burned off, as well. Blood, Glucose 185, 4 units of insulin sliding scale for coverage. You discuss this cough with Mr. Dominec to determine how long he has had it. He has been taking his HIV medication daily. Inform patient about the progression and risk a PCP infection has for a patient with AIDS. Fatigue True Esteem -Assess patient LOC, by walking patient and asking them to take deep breaths. Bed Bath: Assist or Total The nurse identifies self to the nurse triaging patients and is directed to trauma room 4. Educate patient To access your Swift River Virtual Clinicals login to ATI's Student Portal and access the Virtual Clinical card in My ATI. Skin moist, respiratory bilateral wheezes and rhonchi. They were also concerned about the next patient going into that room and the use of the lavatory. Your notice Mr. Thomason is lying supine, appears slightly cyanotic in his lips, is exhibiting more effort to breathe, and is increasingly restless. Provide a few chairs if possible for her family to also be comfortable Vital signs- Check monitor Scenario 3 Dr. Altace, Educational Needs Increased acuity Cough: Lithia Monson Safety Apical pulse rhythm: Regular Irregular Location: Flexes & withdraws = 4 Check input/output for possible dehydration Fall Risk Increased acuity Impaired Skin Integrity, Risk for True Mrs. Pittmon states she has had numbness for years but "now I can't . Notify Physical Therapy (PT) Sa fortune s lve 10 000,00 euros mensuels Sexuality: True. Blood-tinged mucous, productive cough. Acute Confusion True Demerol 25mg SIVP for pain, patient reports 7/10 on pain scale.