NURSING 101 Swift River Answers

NURSING 101 Swift River Answers NURSING 101 Swift River Answers 1. . Linda Yu ● Acuities ○ Educational Needs ○ Fall Risk ○ Health Change ○ Neurological ○ Psychological Needs ● Nursing Concerns ○ Impaired mobil ...

NURSING 101 Swift River Answers NURSING 101 Swift River Answers 1. . Linda Yu ● Acuities ○ Educational Needs ○ Fall Risk ○ Health Change ○ Neurological ○ Psychological Needs ● Nursing Concerns ○ Impaired mobility ○ Fall risk ○ Risk for infection ● Scenario 1 ○ Assess pain level ○ Obtain VS ○ Initial assessment ○ Educate ○ Place med in patient inventory ● Scenario 2 ○ Assess injury ○ Obtain assistance ○ Take VS ○ Skin assessment ○ Notify provider ● Scenario 3 ○ Administer med ○ Address skin tear ○ Obtain bedside commode ○ Prepare for CT ○ Assign UAP ● Scenario 4 ○ Assess leg peripherally ○ Treat for pain ○ Educate ○ Contact power of attorney ○ Collect pre-op labs ● Scenario 5 ○ Assess VS and urinary output ○ Start secondary IV line ○ Have 2nd nurse sign ○ Take VS and start blood ○ Assess patient and VS Q5 for first 15 min 2. . Mary Barkley ● Acuities ○ Educational Needs ○ Health Change ○ Pain Level ○ Psychological Needs ● Nursing Concerns ○ Acute pain ○ Deficient knowledge ○ Grieving ○ Impaired comfort ○ Infection ● Scenario 1 ○ Have pt put on mask ○ Wash hands and don PPE ○ Therapeutic communication ○ Guide her back ○ Set up video chat ● Scenario 2 ○ Alert charge nurse ○ Wash hands and dawn PPE ○ Have aide sit with her ○ Initiate O2 ○ Secure sitter ● Scenario 3 ○ Contact RT ○ Obtain telemetry ○ Ask PCT to secure mask better ○ Don PPE ○ Assist RT ● Scenario 4 ○ Call rapid response ○ Continue to assist RT ○ Give SBAR ○ Call for crash-cart ○ Documentation ● Scenario 5 ○ Encourage provider to consider intubation ○ Offer to contact family ○ Contact assisted living facility ○ Notify provider of absence of advanced directive ○ Assist with intubation 3. . Robert Sturgess ● Acuities ○ Educational Needs ○ Fall Risk ○ Health Change ○ Pain Level ○ Psychological Needs ● Nursing Concerns ○ Chronic pain ○ Risk for constipation ○ Imbalanced nutrition ○ Anxiety ○ Fear ○ Grieving ○ Hopelessness ○ Powerlessness ● Scenario 1 ○ Wash and glove hands ○ Full assessment ○ Seek clarification ○ Check PRN ○ Verify call light ● Scenario 2 ○ Full assessment ○ Educate ○ Place on PCA pump ○ Observe closely ○ Perform re-assessment ● Scenario 3 ○ Use therapeutic communication ○ Educate ○ Notify doctor ○ Contact social services ○ Report and document ● Scenario 4 ○ Therapeutic communication ○ Notify doctor ○ Educate ○ Insert ○ Document ● Scenario 5 ○ Allow family to remain ○ Full assessment ○ Provide comfort measures ○ Pain re-assessment ○ document 4. . Donald Lyles ● Acuities ○ Educational Needs ○ Health Changes ● Nursing Concerns ○ Knowledge deficit ○ Risk for infection ● Scenario 1 ○ Establish responsiveness ○ Call for CODE-blue ○ Check for breathing and carotid pulse ○ Begin chest compressions ○ Pass off chest compressions ● Scenario 2 ○ Assist with airway management ○ Assist with ECG ○ Establish IV ○ Provide patient history ○ Provide medical history ● Scenario 3 ○ Check time from one source ○ Establish when cardiac event began ○ Begin list of meds ○ Document rhythm ○ Remind CODE team ● Scenario 4 ○ Ensure cardio-pads are in place ○ Charge the monitor ○ Announce to CODE team you’re ready ○ CLEAR ○ Ensure no one is touching patient ● Scenario 5 ○ Give 1 mg atropine ○ Reassess ○ Repeat 1 mg atropine ○ Prepare for pace-maker ○ Document 5. . Kenny Barrett ● Acuities ○ Educational Needs ○ Fall Risk ○ Health change ○ Pain level ● Nursing Concerns ○ Acute pain ○ Deficient knowledge ○ Fall risk ● Scenario 1 ○ Perform hand hygiene ○ Re-assess BP ○ Evaluate patient understanding ○ Administer med ○ Document ● Scenario 2 ○ Retake vitals ○ Instruct not to get out of bed ○ Perform comfort measures ○ Request CNA ○ Notify healthcare provider ● Scenario 3 ○ Patient nauseated ○ Patient admitted yesterday ○ Current VS ○ Request possible change ● Scenario 4 ○ VS ○ Strict I&O ○ 500mL normal saline bolus ○ Hold atenolol ○ Contact provider ● Scenario 5 ○ Stress level ○ Communicate ○ Discuss willingness for alternatives ○ Educate ○ Contact provider .............continued......