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Swift River Medical-Surgical Correct
Questions & Answers
Ann Rails - ANSWER Educational - Increased Fall Risk - Increased Health Change - Increased Pain - Increased Psychological Needs - Normal Sensorium - Normal Ann Rails - ANSWER Acute pain Impaired comfort Impaired mobility Disturbed sensory perception Fall, risk for Peripheral neurovascular dysfunction Ann Rails - ANSWER Scenario # Use therapeutic Educate pt. Evaluate pt. learning Place call light Document Scenario # Wash and glove hands Assess Provide comfort measures Notify doctor Document Scenario # Listen to pt. concerns Reassure pt. of options Notify lead nurse/doctor Contact Social Services Document Scenario # Wash and glove hands Visual assessment Do not disturb Verify Call Light
Document Scenario # Assess for bowel sounds Encourage fluids/fiber/ambulation Evaluate pt. understanding Attain fluids/fiber diet Document Arthur Thomason - ANSWER Educational - increased Health change - increased LOC - increased Pain - increased Psychological needs - increased Safety - increased Arthur Thomason - ANSWER Impaired confort Impaired gas exchange Ineffective airway clearance Shock, risk for Anxiety/fear Failure to thrive, risk for Arthur Thomason - ANSWER Scenario # Assess Replace O Use therapeutic Notify Dr. and charge nurse Scenario # Remind physician Explain to physician Assist physician Obtain recent Reassure pt. Scenario # Tap pt. Elevate HOB Call rapid response Start secondary Remain with pt. Scenario # Provide verbal report Emergency intubation
Western blot Bronchoscopy Scenario # Elevate HOB Initiate O2 at 4L Reassess VS Reevaluate amount of blood lost Contact HCP Cameron Daniels - ANSWER Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - normal Neurological - normal Cameron Daniels - ANSWER Acute pain Impaired mobility Deficient knowledge Fall, risk for Infection, risk for Cameron Daniels - ANSWER Scenario # Give tylenol Start another IV Initiate bolus Request additional pain med Reasses temp in 1 hour Scenario # Sit at an eye level Teach Cameron Evaluate understanding Contact charge nurse Document pt's statements Scenario # Provide emotional support Assure pt. Explain to pt. Stress importance Inform pt. Scenario # Make sure accurate wt.
Explain reason for medication Tell the mother that you understand Tell the mother that visitors are welcome Be honest with Cameron Scenario # Assess pt. Perform rapid assessment Ask pt. Inform charge nurse Call local law enforcement Chanthavy Chhet - ANSWER Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - increased Neurological - normal Chanthavy Chhet - ANSWER Acute pain Impaired mobility, risk for Nausea Cultural competence Deficient knowledge Impaired verbal communication Chanthavy Chhet - ANSWER Scenario # Obtain translator Initiate IV Begin fluid and electrolyte Administer IV ABX Consult with MD Scenario # What is going on? We need to stop the bleeding Tell me where you are Who were you talking to? What were the voices telling you? Scenario # Attempt to establish rapport Notify HCP of findings Attempt to restart IV Contact dietary Obtain a sitter
Teach pt. to avoid Teach pt. to apply Scenario # Assess pain Asminister morphine NG tube to LIS Call for triple lumen Address concerns Scenario # Therapeutic communication Pt. teaching Evaluate learning Make referral Dietary consult Dana Fitzgerald - ANSWER Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - normal Neurological - normal Dana Fitzgerald - ANSWER Deficient knowledge Grieving, risk for Dana Fitzgerald - ANSWER Scenario # Sit with the pt. Reinforce provider teaching Assess family support system Reassure the pt. Ask the pt. Scenario # Head-to-toe assessment Inspect catheter Teach pt. Instruct pt. Ask the charge nurse Scenario # Teach the pt. Explain to the pt. Administer pain meds Tell the pt.
Have the pt. ambulate Scenario # Inspect pt's abdomen Auscultate Percuss & palpate Contact provider Tell husband & pt. Scenario # Inform the pt. Provide pt. privacy Lubricate tip of enema Squeeze the contents Have the pt. lay on their side Don Johnson - ANSWER Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - increased Neurological - normal Don Johnson - ANSWER Acute pain Altered body image, risk for Audiology changes, risk for Fluid & electrolyte imbalance, risk for PTSD, risk for Infection, risk for Glenn Massey - ANSWER Acute pain Impaired mobility, risk for Nausea, risk for Deficient knowledge Glenn Massey - ANSWER Scenario # Ensure room was cleaned Disinfect call light Clean and obtain IV pole Obtain burn sheets Notify infection control nurse Scenario # Obtain VS Initial assessment Administer pain meds
Scenario # Administer ABX & start morphine Contact hospice/social work Place pt. on continuous pulse ox Reassess effectiveness Document Scenario # Reassess VS & elevate HOB Continue to provide Seek clarification Call respiratory therapy Provide emotional support Scenario # Full assessment Place pt. on 100% non-rebreather Review PCA pump history DNR armband Discuss with HCP Scenario # Contact HCP Contact chaplain Take pt's family Prepare Mrs. Knox's body Notify social services Hildegard Lowe - ANSWER Educational - increased Fall Risk - increased Health Change - increased Pain - normal Psychological Needs - normal Neurological - normal Hildegard Lowe - ANSWER Impaired mobility, risk for Deficient knowledge Impaired gas exchange, risk for Peripheral neurovascular dysfunction, risk for Risk for infection Ineffective breathing pattern Hildegard Lowe - ANSWER Scenario # Reposition HOB to semi-fowler's Increase supplemental O Orient pt.
Initiate IS treatment Retake VS Scenario # WBC Magnesium RBC Hemoglobin BUN Scenario # Stop infusion Don gloves Inspect site Collect supplies Remove IV & document Scenario # Have secretary Review current Discuss the policy Ask Hildegard Document teaching Talk to daughter Scenario # Don gloves & assist pt. Assess stool Assist pt. to bed Anticipate need Call the physician Place pt. on enteric Janene Whitmore - ANSWER Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - increased Neurological - normal Janene Whitmore - ANSWER Acute pain Bleeding Impaired comfort Deficient knowledge Infection, risk for
Deficient knowledge Jody Rush - ANSWER Scenario # Wash hands Complete full assessment Medicate Encourage positioning Orient friend Scenario # Complete neuro Educate Jody's parents Offer full AM bath Log roll pt. Ensure foley is draining Scenario # Inform pt. & family Draw stat D-Dimer Obtain additional support Ask parents Accompany pt. Scenario # Start O2 100% Provide SBAR Page surgeon STAT Prepare for heparin Assist RRT Scenario # Assist & support Alert ICU Following pt. arrival Provide emotional support Ask charge nurse John Davis - ANSWER Educational - increased Fall Risk - normal Health Change - increased Pain - normal Psychological Needs - normal Neurological - normal John Davis - ANSWER Deficient knowledge
John Davis - ANSWER Scenario # Offer pt. a urinal Perform post-op Assist pt. Tell pt. Ensure side rails Scenario # Assess large dressing site Administer pain meds Assess dressing supply Assess pt's need Document Scenario # Restart new IV Administer nausea med Assess for contraindications Weight the pt. Take VS & provide pt. teaching Scenario # Complete full assessment Apply clean dressing Encourage pt. Continue to encourage Document & inform Scenario # Assess pt's concerns Teach pt. Make referral Consult social services Have pt. verbalize Joyce Workman - ANSWER Educational - increased Fall Risk - normal Health Change - increased Neurological - normal Pain - normal Psychological Needs - normal Sensorium - normal Joyce Workman - ANSWER Enhanced readiness for learning Ineffective health maintenance Imbalanced nutrition
Impaired comfort Impaired mobility Deficient knowledge Fall, risk for Infection, risk for Kate Bradley - ANSWER Scenario # Complete full assessment Secure help Medicate Contact nursing supervisor Complete bed bath Scenario # Reassess VS Report discrepancy Notify HCP Contact IV team Document all findings Scenario # Explain to surgeon Check on labs Contact charge nurse Meet with daughter Assess pt. Scenario # Provide therapeutic Assess last medication Assist the IV team Explain to daughter Contact social services Scenario # Witness daughter Call report 88 y/o female Former nursing home Pt. has a foley Have daughter stay Kathy Gestalt - ANSWER Educational - increased Fall Risk - increased Health Change - increased Pain - normal
Psychological Needs - increased Sensorium - normal Kathy Gestalt - ANSWER Acute Pain Impaired mobility Impaired skin integrity, risk for Anxiety Deficient knowledge Fall, risk for Decisional comfort Disturbed body Kathy Gestalt - ANSWER Scenario # Check pedal cap refill Educate pt. Evaluate understanding Adjust crutches Assist pt. OOB Scenario # Wash & glove VS assessment Administer anit-pyretics Verify call light Document results Scenario # Inspect cast site Assess toe movement Notify Dr. Document results Scenario # Assess pain Elevate extremity Educate pt. Notify lead nurse/Dr Retrieve cast removal tool Scenario # Use therapeutic Notify lead nurse/Dr Consult social services Evaluation pt. Document consults
Dotty Hamilton - ANSWER Educational - increased Fall Risk - normal Health Change - normal Pain - normal Psychological Needs - increased Neurological - normal Dotty Hamilton - ANSWER Bleeding, risk for Impaired comfort, risk for Deficient knowledge Infection, risk for Dotty Hamilton - ANSWER Scenario # Contact surgeon Complete pre-op Ensure surgical consents Check to see Pt. teaching Scenario # Wash hands Complete full assessment Check wound sites Use therapeutic Encourage first IS Scenario # Reassure & communicate Check blood glucose Administer ABX Encourage aggressive IS Start PCA pump Scenario # Reassure pt. Complete full pt. assessment Assess whether or not Obtain labs Notify HCP Scenario # Complete full assessment Place pt. on telemetry Check foley Assist anesthesia Explain to pt.
Scenario # Have family step out Bring the family in Offer to the family Contact funeral home Ask nursing manager Glenn Massey - ANSWER Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - normal Neurological - normal Keaton Henderson - ANSWER Scenario # Introduce Take vitals Auscultate lungs Inspect pleurovac Mark drainage level Scenario # Assess VS Assess insertion site Check pleurovac Administer pain meds Encourage use of IS Scenario # Asses for mediastinal shift Administer 100% O Auscultate lungs Assess pleurovac Cal rapid response Scenario # Explain to pt. Obtain 16 gauge angiocath Set up sterile Obtain & fill Assist with insertion Scenario # Assess VS Auscultate lungs
