Answers to the questions PDF

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Answers to the questions...

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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

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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

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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

6. Marcella Como ● Acuities ○ Educational needs ○ Health change

○ Pain level ○ Psychological needs ● Nursing Concerns ○ Acute pain ○ Readiness for enhanced immunization status ○ Fear ○ Grieving ○ Risk for infection ○ Anxiety ○ Compromised family coping ○ Social isolation ○ Ineffective coping ○ Rape-trauma syndrome ○ Disturbed energy field ● Scenario 1 ○ Therapeutic communication ○ Full assessment ○ Emotional support ○ Documentation ● Scenario 2 ○ Therapeutic communication ○ Educate ○ Provide supplies ○ Offer to assist ● Scenario 3 ○ Therapeutic communication ○ Ask open-ended questions ○ Seek clarification ○ Summarize discussion ● Scenario 4 ○ Resetate or paraphrase ○ Acknowledge ○ Review ○ Notify ○ Document ● Scenario 5 ○ Review labs ○ Educate patient ○ Provide emotional support ○ Discuss support groups 7. Tim Jones ● Acuities ○ Educational needs

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○ Fall risk ○ Health change ○ Neurological ○ Pain level ○ Psychological Nursing Concerns ○ Defensive coping ○ Ineffective health maintenance ○ Risk for PTSD ○ Risk for injury at home Scenario 1 ○ Wash hands ○ Reassure patient ○ Interview patient ○ Complete assessment ○ Notify charge nurse Scenario 2 ○ Use therapeutic communication ○ Seek clarification from Mr. Jones on why he does not want to leave the room ○ Reassure Mr. Jones that he will be safe during his hospital stay ○ Administer prescribed anxiolytic medication prior to transfer to CT area ○ Offer UAP to accompany Mr. Jones during the CT process Scenario 3 ○ Assess for injuries ○ Assist back to bed ○ Provide hygiene ○ Remind him to seek assistance ○ Obtain sitter Scenario 4 ○ Notify healthcare provider for change in respiratory assessment ○ Administer nebulizer treatment per HCP order ○ Reassess respiratory status ○ Encourage Mr. Jones to cough and take deep breaths hourly ○ Document findings from repeat assessment Scenario 5 ○ Talk with Mr. Jones about his wishes for end of life ○ Call Mr. Jones’ children per his request ○ Ask Mr. Jones if he would like for a chaplain or minister to be called ○ Discuss options with Mr. Jones regarding end of life care ○ Notify the social worker of need for a new nursing home placement option

8. Kathy Gestalt ● Acuities

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○ Educational needs ○ Fall risk ○ Health change ○ Pain level ○ Psychological needs Nursing Concerns ○ Acute pain ○ Impaired mobility ○ Risk for impaired skin mobility ○ Anxiety ○ Deficient knowledge ○ Risk for falls ○ Decisional conflict ○ Disturbed body Scenario 1 ○ Check cap refill ○ Educate patient ○ Evaluate ○ Adjust crutches ○ Assist out of bed Scenario 2 ○ Wash and glove hands ○ Vitals ○ Administer antipyretic meds ○ Verify call light ○ Document Scenario 3 ○ Inspect cast site ○ Assess toe movement ○ Notify doctor ○ Document Scenario 4 ○ Pain assess ○ Elevate extremity ○ Educate patient ○ Notify lead nurse/doctor ○ Retrieve cast removal Scenario 5 ○ Use therapeutic communication ○ Notify lead nurse/doctor ○ Consult social service ○ Evaluation patient ○ Document results

9. Preston Wright ● Acuities ○ Educational needs ○ Fall risk ○ Health change ○ Pain level ● Nursing Concerns ○ Acute pain ○ Altered body image ○ Impaired physical mobility ○ Impaired tissue integrity ○ Risk for imbalanced nutrition ○ Risk for infection ○ Risk for injury related to falls ● Scenario 1 ○ Assess pain level ○ Assess documented pain level ○ Review medication orders ○ Prepare and administer ○ Reassess pain level ● Scenario 2 ○ Assess willingness to learn ○ Eliminate distractions ○ Explain reationales ○ Assess understanding ○ Document ● Scenario 3 ○ Remove old dressing ○ Assess for presence of necrotic tissue ○ Assess and document condition of skin surrounding ○ Measure wound size ○ Re-apply ● Scenario 4 ○ Don clean gloves ○ Remove clean gloves ○ Clean wound ○ Place sterile moistened gauze in wound ○ Secure dressing ● Scenario 5 ○ Explain signs and symptoms of wound infection ○ Encourage high protein snacks ○ Assess understanding

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Alert case manager Call report to home care nurse

10. Carlos Mancia ● Acuities ○ Educational needs ○ Fall risk ○ Health change ○ Psychological needs ● Nursing Concerns ○ Fatigue ○ Impaired gas exchange ○ Ineffective airway clearance ○ Anxiety ○ Deficient knowledge ○ Fear ○ Risk for social isolation ○ Noncompliance ○ Readiness for self care ● Scenario 1 ○ Don PPE ○ Allow for non-compliance ○ Do not probe further ○ Verify call light ○ Document results ● Scenario 2 ○ Obtain translator ○ Offer masks ○ Educate patient ○ Evaluate ○ Obtain spanish signs ● Scenario 3 ○ Obtain translator ○ Wash hands ○ Gown and mask ○ Don gloves ○ Administer med ● Scenario 4 ○ Educate caller ○ Evaluate caller ○ Refer call to contact health dept ○ Notify doctor ○ Document

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Scenario 5 ○ Obtain translator ○ Use therapeutic communication ○ Educate patient ○ Evaluate learning ○ Document

11. Joyce Workman ● Acuities ○ Educational needs ○ Health change ● Nursing Concerns ○ Enhanced readiness for learning ○ Ineffective health maintenance ○ Imbalanced nutrition ○ Risk for injury ● Scenario 1 ○ Ask her to explain what she knows ○ Explain in layman terms ○ Discuss lifestyle choices ○ Discuss lifestyle changes ○ Document ● Scenario 2 ○ Assess her knowledge of nutrition ○ Ask for 24-hour recall ○ Educate on healthier options ○ Provide mediterranean diet ○ Ask her to demonstrate understanding ● Scenario 3 ○ Assess preferred exercise ○ Ensure no pre-existing conditions ○ Provide exercise routine ○ Review with her safety measure ○ Teach back method ● Scenario 4 ○ Assess glucose level ○ Provide 20G carb ○ Provide another 20G carb ○ Reassess ○ Provide additional teaching ● Scenario 5 ○ Assess understanding of regimen ○ Explain to her about carb foods

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Explore new ways of cooking Provide info on support groups Document

12. Sarah Kathryn Horton ● Acuities ○ Educational needs ○ Fall risk ○ Health change ○ Pain level ○ Psychological needs ● Nursing Concerns ○ Acute pain ○ Anxiety ○ Disturbed personal identity ○ Impaired physical mobility ○ Impaired skin integrity ○ Risk for post trauma syndrome ○ Alteration of protective mechanisms ● Scenario 1 ○ Wash hands ○ Assess respirations ○ Do not disturb ○ Reduce stimuli ○ Document ● Scenario 2 ○ Wash hands ○ Assess orientation ○ Medicate ○ Attempt de-escalation ○ Document ● Scenario 3 ○ Gather supplies ○ Wash hands ○ Explain procedure ○ Provide morphine ○ Perform dressing change ● Scenario 4 ○ Educate about Paxil ○ Reinforce past coping ○ Educate family about active listening ○ Educate family regarding intervention ○ Document

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Scenario 5 ○ Assess orientation status ○ Therapeutic communication ○ Assist back into wheelchair ○ Escort patient ○ Provide report

13. Julia Monroe ● Acuities ○ Educational needs ○ Fall risk ○ Health change ○ Pain level ● Nursing concerns ○ Acute pain ○ Impaired comfort ○ Impaired mobility ○ Risk for fall ● Scenario 1 ○ Perform assessment ○ Ask if any procedures ○ Ask about metal ○ Ask if patient understands ○ Ensure informed consent signed ● Scenario 2 ○ Comfort ○ Provide education ○ Explain treatment plan ○ Evaluate understanding ○ Document ● Scenario 3 ○ Assist back to bed ○ Performed focused assessment ○ Draw labs ○ Request order for telemetry ○ Place call light in reach ● Scenario 4 ○ Assess patient ○ Establish IV ○ Administer dig ○ Monitor for adverse effects ○ Request repeat potassium lab ● Scenario 5

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Check leads Perform focused assessment Start O2 Call rapid response Educate patient

14. Estelle Hatcher ● Acuities ○ Educational needs ○ Fall risk ○ Health change ○ Pain level ● Nursing Concerns ○ Acute pain ○ Risk for electrolyte imbalance ○ Impaired comfort ○ Deficient knowledge ○ Risk for falls ○ Risk for infection ● Scenario 1 ○ Introduce yourself ○ Full assessment ○ Educate PT ○ Evaluate PT ○ Provide comfort ● Scenario 2 ○ wash/glove hand ○ Inspect pain location ○ Check proper positioning ○ Verify call light ○ Notify doctor ● Scenario 3 ○ Educate patient ○ Evaluate understanding ○ Remove NG-tube ○ Order new clear liquid diet ○ Document results ● Scenario 4 ○ wash/glove hands ○ Full assessment ○ Encourage incentive spirometry ○ Verify call light ○ Document

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Scenario 5 ○ Use therapeutic communication ○ Educate ○ Evaluate understanding ○ Verify call light ○ Document

15. Arthur Thomason ● Acuities ○ Educational needs ○ Health change ○ LOC ○ Pain level ○ Safety ● Nursing Concerns ○ anxiety/fear ○ Impaired gas exchange ○ Ineffective airway clearance ● Scenario 1 ○ Assess ○ Replace O2 ○ Therapeutic communication ○ Notify doctor ● Scenario 2 ○ Remind physician to wash hands ○ Explain to physician what interventions ○ Assist physician ○ Obtain recent chest x-rays ○ Reassure patient ● Scenario 3 ○ Tap patient ○ Elevate head of bed ○ Call rapid response ○ Start secondary large bore IV ○ Remain with patient ● Scenario 4 ○ Provide verbal report ○ Emergency intubation ○ Assume role ○ Obtain patient record ○ Provide information for MD ● Scenario 5 ○ Explain condition has worsened

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Explain he is receiving higher level of care You have them remain with you You escort them with you to ICU You call his doctor

16. Ramona Stukes ● Acuities ○ Educational needs ○ Fall risk ○ Health change ○ Pain level ● Nursing Concerns ○ Risk for bleeding ○ Risk for deficient fluid volume ○ Impaired mobility ○ Risk for fall ○ Risk for infection ● Scenario 1 ○ Wash and glove hands ○ Full assessment ○ Allow expression of feelings ○ Educate patient ○ Evaluate ● Scenario 2 ○ Wash and glove ○ Full assessment ○ Check NG tube placement ○ Administer IV ● Scenario 3 ○ Full assessment ○ Educate ○ Evaluate ○ Notify lead nurse ○ Consult wound care ● Scenario 4 ○ Discuss with patient ○ Notify lead nurse ○ Contact social services ○ Update patient ● Scenario 5 ○ Follow HIPPA ○ Explain HIPPA ○ Offer resource assistance

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Contact wound care Document

17. Ann Rails ● Acuities ○ Educational needs ○ Fall risk ○ Health change ○ Pain level ● Nursing Concerns ○ Acute pain ○ Impaired comfort ○ Impaired mobility ○ Disturbed sensory perception ○ Risk for falls ○ Peripheral neurovascular dysfunction ● Scenario 1 ○ Therapeutic communication ○ Educate ○ Evaluate ○ Place call light ○ Document ● Scenario 2 ○ Wash and glove hands ○ Assess ○ Provide comfort measures ○ Notify doctor ○ Document ● Scenario 3 ○ Listen to concerns ○ Reassure patient ○ Notify lead nurse ○ Contact social services ○ Document results ● Scenario 4 ○ Wash and glove hands ○ Visual assessment ○ Do not disturb ○ Verify call light ○ Document ● Scenario 5 ○ Assess for bowel sounds ○ Encourage fluids/fiber

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Evaluate understanding Attain fluids/fiber diet Document

18. John Duncan ● Acuities ○ Educational needs ○ Fall risk ○ Health change ○ Pain level ● Nursing Concerns ○ Deficient fluid volume ○ Risk for electrolyte imbalance ○ Fatigue ○ Risk for falls ○ Noncompliance ● Scenario 1 ○ Assess I&O ○ Construct dietary consult ○ Acquire daily weight and food intake ○ Evaluate outcome ● Scenario 2 ○ Full assessment ○ Check I&O ○ Teach patient ○ Document ● Scenario 3 ○ Wash and glove hands ○ Provide emesis basin ○ Vitals ○ Administer antiemetic ○ Evaluate medication ● Scenario 4 ○ Vitals ○ Assessment of bowel movement ○ Administer protocol antidiarrheal ○ Document results ○ Include patient condition change in shift report ● Scenario 5 ○ Inform and educate spouse ○ Evaluate/modify plan of care ○ Assess food consumption ○ Document

19. Viola Crumble ● Acuities ○ Educational needs ○ Fall risk ○ Health change ○ Pain level ● Nursing concerns ○ Acute pain ○ Risk for bleeding ○ Impaired mobility ○ Risk for falls ○ Ineffective self-health management ○ Risk for infection ● Scenario 1 ○ Assess bowel sounds ○ Administer PRN constipation meds ○ Encourage fluids ○ Evaluate understanding ○ Review pain medication ● Scenario 2 ○ Check orders ○ Educate ○ Offer bedpan ○ Record I&O ○ Verify call light ● Scenario 3 ○ Obtain vital machine ○ Wash and glove hands ○ Identify patient ○ Assess vital results ○ Document ● Scenario 4 ○ Wash and glove hands ○ Administer antipyretic meds ○ Encourage fluids ○ Notify doctor ○ Document ● Scenario 5 ○ Notify PT ○ PT to educate patient ○ Read PT report ○ Re-assess patient

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Evaluate plan

20. Richard Dominec ● Acuities ○ Educational needs ○ Health change ○ Pain level ○ Safety ● Nursing concerns ○ F ● Scenario 1 ○ Full assessment ○ Comfort ○ Check surgical ○ Inform partner ● Scenario 2 ○ Educate ○ Discuss understanding about POC ○ Discuss follow up ○ Offer assistance ○ Determine from ● Scenario 3 ○ Discuss cough ○ Notify doctor ○ Explain concern for infection ○ Notify charge nurse ● Scenario 4 ○ Inform patient about progression ○ Obtain and provide ○ Encourage discussing ○ Take vitals ○ Document ● Scenario 5 ○ HIPPA protected ○ Remind staff ○ Leave breakroom ○ Report to privacy officer ○ Report to nurse 21. Lithia Monson ● Acuities ○ Educational needs ○ Fall risk

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○ Health change ○ Pain level ○ Psychological needs ○ Sensorium Nursing concerns ○ Risk for bleeding ○ Imbalance nutrition ○ Self-care deficit ○ Acute confusion ○ Risk for falls ○ Failure to thrive Scenario 1 ○ Perform neuro assess ○ Reorient ○ Assess for fall risk ○ Offer nutrition/toilet Scenario 2 ○ Explain reason for assessment ○ VS ○ Apply restraint ○ Perform circulatory evaluation ○ Request sitter Scenario 3 ○ Present reality ○ Release restraints ○ Reapply restraints ○ Perform circulatory evaluation ○ Document Scenario 4 ○ Use therapeutic communication ○ Attempt to orient ○ Perform circulatory evaluation ○ Offer nutrition ○ Document Scenario 5 ○ Check monitor ○ Apply nasal cannula ○ Vital reassessment ○ Notify lead nurse/dr ○ Remain with patient

22. Sarah Getts ● Acuities

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○ Educational needs ○ Fall risk ○ Health change ○ Psychological needs ○ Sensorium Nursing concerns ○ Electrolyte imbalance ○ Risk for impaired fluid volume ○ Risk for ineffective renal perfusion ○ Acute confusion ○ Risk for falls ○ Failure to thrive Scenario 1 ○ Wash and glove hands ○ Full assess ○ Monitor and evaluate fluid intake ○ Educate patient ○ Document Scenario 2 ○ Wash and glove hands ○ Full assess ○ Apply fall risk bracelet ○ Document Scenario 3 ○ Offer assistance ○ Remain with pt ○ Therapeutic communication ○ Notify lead nurse ○ Document Scenario 4 ○ Visual assess ○ Call rapid response ○ Apply oxygen ○ Establish second IV ○ Remain with patient Scenario 5 ○ Give verbal report ○ Escort patient ○ Notify family ○ Document

23. Virginia Smith ● Acuities

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○ Educational needs ○ Health change ○ Pain level ○ Safety Nursing Concerns ○ Acute pain ○ Impaired physical mobility ○ Impaired skin integrity ○ Knowledge deficit ○ Disturbed body image Scenario 1 ○ Ask patient to explain procedure ○ If patient statement differs ○ Stay with patient ○ Contact head nurse ○ Procedure is cancelled Scenario 2 ○ Therapeutic communication ○ Validate NPO ○ Encourage to ambulate ○ Connect telemetry ○ Provide few chairs Scenario 3 ○ VS ○ Assess ○ Talk with her stating surgery over ○ Allow husband to come into ○ Document Scenario 4 ○ Provide operative summary ○ Present health assessment ○ Report current urinary output ○ Request time she can arrive ○ Explain to her family Scenario 5 ○ Full assessment ○ Provide for physical and thermal comfort ○ Therapeutic communication ○ Begin post op education ○ Notify family

24. Linda Pittmon ● Acuities

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○ Educational Needs ○ Fall Ris...