Kenny Barrett - Concepts of Nursing III PDF

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Concepts of Nursing III...

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Kenny Barrett Room 301 Kenny Barrett, 64 years old, was admitted for observation of initial administering of BP his treatment with blood pressure of 220/124 after visiting his doctor for a routine physical. ECG was unremarkable. No past history of HTN. Past medical history includes hyperlipidemia, current elevated triglycerides, and a history of 1 pack a day smoker for the past 20 years. Vital signs are Temp 98.9F, BP 178/90, P 88, RR 18 SaO2 95% on Room air. IV with NS @ 125 mL/ hr. Patient has been complaining of a headache and dizziness. He is a patient of Dr. Adams.

You responded correctly to 4 out of 6 evaluations: Your response Incorrect acuity Gas exchange (no) Incorrect acuity Interpersonal violence Incorrect (no) acuity Addiction (yes) Incorrect acuity Cognition (no) Incorrect acuity Sexuality (no) Incorrect acuity Category Perfusion (yes)

Explanation Patient is at risk because of his BP and pulse No indication at this time No indication at this time History of 1 pack a day smoker for the past 20 years Patient is AAO x 4 No evidence of abnormal sexual history

Scenario 1 When reviewing your patients’ vital signs, taken by the UAP, you notice Kenny has a blood pressure of 190/110 and a pulse of 105. What actions by the nurse are appropriate?

You correctly selected 3 out of 5 actions: Correc Your t Answe Answe Stat r r us Label No Yes Reassess blood pressure and pulse

No

Yes

No

No

No

No

No

No

Explanation All vital signs taken that are abnormal by UAP should be confirmed by licensed nurse Educate UAP Abnormal values regarding require further notification of assessment by abnormal range licensed nurse and of vital signs need to be reported by the UAP immediately Administer There is no order for BP second dose of medicine at this point BP medicine There is no order for Ask patient to patient to be on bed remain in bed rest until further evaluated Provide bolus of A bolus would not help IV fluids lower patient’s BP

Scenario 2 When re-taking the patient’s BP, you get a reading of 184/108 and a pulse of 102. Report finding to Dr. Adams using SBAR. What should be included in the “S”?

You correctly selected 3 out of 5 actions: Your Answe Correct Stat r Answer us Label No Yes Current elevated BP No

Yes

No

No

No

No

No

No

Explanation This is the current situation and reason for the call State patients Introductions are done name and date at the beginning of all of birth SBAR’s History of History is included hypertension during the background, “B” Request Recommendations are medication to including during the reduce BP “R” Inform HCP that History is included during the patient is a background, “B” smoker

Scenario 3 In continuing with the SBAR, what should be included in the “B”?

You correctly selected 2 out of 5 actions: Correc Your t Answe Answe Stat r r us Label No Yes Reason the patient was admitted No Yes History of smoking No

No

No

Yes

No

No

Explanation This information is included in the “B” of SBAR This information is included in the “B” of SBAR This information would Patient is complaining of a be included in the assessment, “A”, as it headache and is current and not dizziness. history. Patient has past This information is medical history included in the “B” of SBAR includes hyperlipidemia Patients lab Although this values are information would be normal included here, patient’s lab values are abnormal; current elevated triglycerides.

Scenario 4 In continuing with the SBAR, what should be included in the “A”?

You correctly selected 3 out of 5 actions: Correc Your t Answe Answe Stat r r us Label No Yes Give current vital signs No

No

No

Yes

No

No

No

No

Explanation Assessment would include current vital signs No history of History should be hypertension included in “B” Patient is Current patient complaining of a complaints are headache and included in “A” dizziness Request an anti- Request for medications are hypertensive included in the “R” medication Patient has an This medication is allergy to irrelevant to the Lipitor, situation/assessment Atorvastatin

Scenario 5 In continuing with the SBAR, what should be included in the “R”?

You correctly selected 3 out of 5 actions: Your Answe Correct Stat r Answer us Label No Yes Request for change in IV rate from 125mL/hr. to 50mL/hr. No No Request Amoxicillin, 250mg PO BID No Yes Suggest/ask for an anti-hypertensive medication No No Report error made by UAP in failure to report No

No

Explanation Fluid volume increase can further elevate blood pressure No indication of infection

Elevated BP of this significance requires treatment This information should be reported to Nurse manager, not HCP Educate patient on This is a nursing intervention, no dangers of smoking order is required...