20ga. Check input/output for possible dehydration Scenario 1 Determine from medical record if partner is aware of his recent AIDS diagnosis. Linen Change Pulse Ox: ___________ % on ____________FiO2; Room Air; Delivery Device Scenario 3 Acquire daily weight and food intake Ms. Gestalt is second day post-op and has requested to get out of bed and to ambulate to bathroom. Cough: Acute Confusion False Full head to toe neuro assessment. Primary: Check LOC, Orientation, Breathing, Circulation, Brief Neuro assessment to include spinal pain or deformities, Obvious injuries. except 115 pulse, which is normal for him. Palliative care. However, these abnormal cells do not have the capability to spread to other parts of the body. No Known allergies (NKA). You explain that his condition has worsened and now he has been taken to ICU. Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. He was initially sedated with versed 2mg, and Fentanyl 100 mg by the EGD nurse, but the patient was not tolerating the procedure, so anesthesia was called to administer propofol. Non-significant past medical Hx. IV maintenance fluids with D5 1/2 NS at 125ml per hour in left forearm. Scenario 5 Scenario 4 Scenario 3 Eye opening Spontaneous = 4 Notify lead nurse/doctor Document findings/results, Ann Rails, 38 years old, c/o back pain, non-significant past medical history. While assessing the patient, Mr. Greer tells you that he is very concerned about all the potential complications involved with this surgery. Assess for fall risk However, he quit three years ago when he remarried; he and his wife have a nine-month-old baby. NKDA Assessment The client vital signs are: Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%, Neuro WNL alert and cooperative. Use therapeutic communication/Active Listening Vital signs taken by automatic B/P Cuff q 15 minutes Wash and glove hands 1Perform full assessment and provide anti-nausea medicine. Skin warm and, dry, all vital signs in WNL except 115 pulse, which is normal for him. -Reinforce to the patient to not get out of bed Chronic Pain False Scenario 3 RLE: ______________ LLE: ______________, Casts/Splits: ____________________________, Motor response Verbal command = 6 Inspect cast site Impaired Home Maintenance Management r/t Client or Family False Use therapeutic communication/Active Listening No known allergies. Robert Sturgess - Swift River Swift River University Nightingale College Course Concepts of Nursing I (BSN 246) Academic year2022/2023 Helpful? Chronic Confusion False Mr. Mancia is holding Catholic Rosary in hand and is crying as you enter the room. 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 . Educational needs: Increased acuity Infection, Risk for False Impaired Skin Integrity, Risk for False Psychological Needs Increased acuity Glasgow Coma Scale 0-15 Musculoskeletal No weight bearing today. Infection, Risk for False She is with her physician. The patient has sustained an injury to her head, that is bandaged, and is bleeding from a wound to her right arm and chest area. Remain with patient He is a local TV news reporter that was filming an event at the county fair when there was an explosion. Skin integrity at risk True Ronald Burgundy Powerlessness: True, Scenario 1 Scenario 4 Psychological Needs: Increased acuity Document and provide copy for Mr. Dominec to share with his follow up appointment tomorrow. Skin: Warm/dry Clammy/diaphoretic Skin Turgor: Brisk Tenting His overall health is good, and he has known he has been HIV positive for the past five years. Taking HIV Meds prophylaxis. Blood Glucose 185, 4 units of insulin sliding scale for coverage. Imbalanced Nutrition True Disturbed Sensory Perception True His original lymph node biopsy was negative. Senario 3 -Using therapeutic communication inform Mr. Greer that there are many treatment options, and not to leave until the HCP can come and speak with him Remain with patient and reassure Imbalanced Nutrition True 45 terms. Document Results/Findings Connect telemetry Powerlessness True. He also has a history of hypertension and takes Tenormin (Atenolol) and Atorvastatin (Lipitor). Encourage to ambulate with assistance to void if needed He is aware that he may not have an erection and may need depends for bladder incontinence. Fall, Risk for True Capillary Refill: _________ seconds Adjust crutches Safety- Demerol 25mg SIVP for pain, patient reports 7/10 on pain scale. Mr. Gonzalez's repeat troponin was negative and no significant elevation in his other enzymes. Paul Greer Vital signs -Temp 97.2, BP 96/74, P 82, RR 20, SaO2 97%. Scenario 2 DSD (dry sterile dressing), forehead laceration clean and dry intact. Health Change Increased acuity Pain re-assessment -Reapply the NC that he was admitted with at 2L Patients vital signs are BP: 100/58, P: 106, R: 28, PaO2: 92%, T: 97.1 F, 36.2 C. Purposive Communication Module 2, Chapter 1 - Summary Give Me Liberty! Offer masks to visitors Scenario 4 Discuss follow up with his doctor. Sa fortune s lve 10 000,00 euros mensuels Therapeutic communication. Psychological Needs Normal acuity Attempt to orient to person, place, and time The patient has been scheduled for an EGD today and has an order for Omeprazole (Prilosec) and Carafate (sucralfate). Anxiety False Full assessment The provider advises the Nurse to draw a stat CBC, give a liter bolus of NS, and repeat CBC. The 'Strandperle' (lit. Tear, Ecchymosis, Contusions, Bruising Scenario 5 Full assessment Fall, risk for: False Recent chest X-ray shows diffuse bilateral interstitial infiltrates in all lobes. Bleeding, Risk for False Nausea False Clear liquid diet. Use therapeutic communication/Active Listening Discuss his understanding about the plan of care. Color:__________ Dr. Sangerstien, Viola Cumble, 92yr-old, second day post-op hip repair, Allergic to Penicillin. Scenario 3 Shock, Risk for: False Toileting, Medications List/Times of Medications/Routes of medication, Neurological Assessment -Call security for assistance and compliance officer GI WNL. Apply nasal cannula After two hours, Mr. Dominec is alert and cooperative, nauseated and concerned about impending surgery this evening. Estimate the length of the Neptunian year given that the Earth is 1.50108km1.50 \times 10^{8} \mathrm{km}1.50108km from the Sun on the average. The nurse was told by the gastroenterology nurse that they really struggled before they called anesthesia and they may have caused an esophageal abrasion. Deficient Knowledge False They would also like to start Radium-223. His coughing, to clear his airway, appears ineffective. Scenario 1 Nausea False BP 154/89, P 94 F, R 22, T 98.3F, SaO2 95% on room air. Scenario 1 You have them remain with you, seated in comfortable place, while you call ICU and attempt to locate physician for them. Vital signs -Temp 98.8, BP 102/76, P 102- irregular, RR 22, SaO2 90%, cardiovascular on telemetry with Sinus irregular rhythm. Blood-tinged mucous, productive cough. Scenario 3 Tubes: None Salem Sump Nasoduodenal PEG J-Tube pH: ______ Your Swift River Virtual Clinicals account has been linked to your ATI Student account. -Notify HCP of neuro findings Increased fall risk. Vital signs -Temp 99.1, BP 124/62, P 77, RR 20, SaO2 91%. Ms. Cumble states that she has not had a BM for three days. Upon entering room, you find Mr. Sturgess is quiet, appears tense and rigid but states, "I am feeling fine." . 50% intake. Seek clarification -Transport Mr. Burgundy to his room Assess Mr. Greer has just returned from surgery. Dr. Rondeau, Educational Needs Increased acuity Provide comfort and pain measures Leave to break room and not continue in conversation. Cardiovascular Assessment Odor: __________, No Deficient knowledge: True Fear True Remain with patient Employ therapeutic communication: present reality Notify doctor Gastrointestinal Assessment Fall, Risk for True No known allergies (NKA). The heartburn has become worse since he started treatment for his URI. Due to this, the provider would like him to stay in the hospital for observation. Put the patient on O2 NC and Fentanyl 25mcg IVP for pain. To access your Swift River Virtual Clinicals login to ATI's Student Portal and access the Virtual Clinical card in My ATI. Skin warm and dry, daily dressing changes, T-tube without drainage. Verify call Light/bed safety precautions Tunneled, site _______________ Implanted port, accessed _____________________ Vital signs -Temp 97.2, BP 96/74, P 82, RR 20, SaO2 97%. In the interim, start an IV and start infusing Ringers Lactate. Reorient Patient to person, place, & time Health Change Increased acuity -Restart the IV and draw CBC Verify Call Light/Bed Safety precautions Health Change Increased acuity Wash and glove hands Take vital signs before leaving the hospital again. Imbalanced Fluid Volume, Risk for True Explain that he will probably not be going home at least until his doctor sees him. Apical pulse rhythm: Regular Irregular Location: Nutritional Intake: Adequate Inadequate BMI: He has been taking his HIV medication daily. Impaired Home Maintenance management r/t client or family False Vital assessment Upon assessment, you determined that she is confused to person, time, and place but is easily directable. Ambulates with minimal assistance. Biopsies were sent to determine the treatment. Acute Pain True Provide a few chairs if possible for her family to also be comfortable Obtain Clinical Hours 24/7/365 In-Class and Lab Learning Resource Improve Clinical Practice #ozerysnackingrounds I am so excited to be partnering with Ozery Family Bakery today. His children are visiting, and they are very supportive. Scenario 4 Filmotka filmu Najvyia ponuka (2013). -Recheck Tilts after the NS bolus is complete.T Kathy Gestalt Document Procedure When the HCP realizes who he is, he tells the nurse to move the patient in the treatment room down the hall and put Mr. Burgundy in there. Neck: ______________ Place pt on PCA pump Blood, Glucose 185, 4 units of insulin sliding scale for coverage. -Discuss and determine sitter availability Chronic Pain False Intermittent/Continuous Other: Acute Confusion: True Respiratory Assessment Administer protocol antidiarrheal medication Electrolyte Imbalance False Offer assistance IV Fluids: INT lock IV Fluids ______________@ _____________ mL/hr Date on tubing: Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Chronic Pain, Risk for constipation, impaired nutrition, anxie, 4 units on insulin sliding scale for coverage, Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. 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Respiratory Effort: Relaxed, Regular, Non-labored Pursed lip breathing Labored Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. High fall risk. Scenario 5 Document results and findings Abdomen: Flat Rounded Scaphoid Distended Palpation: Soft Taut Rigid Evaluate understanding sounds= 2 Pain, Acute True Fall, Risk for True He is married, and his wife is requesting to stay at his side. Diet as tolerated. Today's weight 226. She has arrived in pre-op and about to have surgery this morning. -Start IV She has received a dose of Hydrocodone for PRN pain 20 minutes ago. Ms. Getts is being transferred as an emergency to Critical Care. The bed arrives tomorrow. Impaired Mobility True Senario 4 Your notice Mr. Thomason is lying supine, appears slightly cyanotic in his lips, is exhibiting more effort to breathe, and is increasingly restless. Constipation, risk for: True Provide verbal report to team members who respond to rapid response Vital Signs: B: 160/92, P: 96, R: 22, SpO2: 98, T: 98.9F, 37.1C. -Verify that discharge orders have been written, provide discharge instructions, and in inform provider about the chest pain. Infection, Risk for True Scenario 5 You are the now the Surgical ICU nurse assigned to her. Bleeding False Patient, and family upset regarding dx. You arrive in room to find Ms. Monson talking to herself. Shock, Risk for False Dr. Donofrio. Vital signs are to be taken BID, and it is now time. The patient has a pneumothorax that requires a chest tube placement. -Ensure there is a full O2 tank on the gurney, place patient on Nasal Cannula Arthur Thomason Genitalia: WNL (skin intact, no lesions) Abnormalities Describe: __________________________ Teach Cameron. 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. signs someone is thinking about you telepathically, giles county tn shooting, expired drivers license florida grace period,
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