Deficient knowledge The dx tests were completed and Dr. Gray has informed the pt of the dx of HF and tx w/ digoxin. Read PT report Give 1mg atropine Using therapeutic Use therapeutic Notify housekeeping, Educational - increased Provide Morphine sulfate IVP as prescribed Administer nausea med Self-care deficit Full assessment including both lying/standing Verify soft, low sodium Impaired home maintenance management: False Assist with applying Scenario #3 Scenario 4 Complete neuro Scenario 3 Assess for fall risk Complete full assessment Reassess pt. Document Pulses above the stump are palpable at 2+, skin is warm and dry. Transport Mr. Burgandy Start a saline lock Offer full AM bath Educate Jody's parents She was then sent to the lab for ordered lab tests. Contact charge nurse Psychological Needs - increased Provide medical hx including medication hx and allergies Notify respiratory therapy Set up sterile Medicate - Impaired physical mobility Scenario 5 Ask pt. Scenario 2 Contact charge nurse -Assess peripheral vision Explain to pt. Ineffective Coping: False Educate pt. Scenario #4 Ms. Rails shares with you her fear of being discharged home to an abusive husband. Psychological Needs: Increased acuity Administer IV ABX -Provide mask for patient You arrive in room to find Ms. Monson talking to herself. Stop the platelets Encourage fluids Impaired mobility, risk for Pain - normal Ask pt. Evaluate understanding Sacrum pressure injury demonstrates underlying bone exposure wound measures 4cm x 6cm x 3cm depth w/ tunneling noted on the rt side. Call for CODE-blue Notify HCP Pre-op education Cal rapid response Apply clean gloves -Apply new probe cover to probe before assessing temperature Grieving Love and Belonging- Document Document Deficient Fluid Volume: True Scenario #2 Serum Potassium Fall Risk: Increased acuity Do not disturb Ensure documentation Scenario 4 -Review plan of care verbally with the patient Scenario 4 Vital assessment Linda Yu 2. Schedule cardiac Assure the pt. Evaluate pt understanding Scenario 1 Anxiety: True Scenario 3 2-Ensure UAP has proper PPE Assess and document the condition of the skin surrounding the pressure injury in terms of color, temperature, texture and moisture. Assist w/ applying ECG leads Provide one-to-one After your AM assessment, the pt's call light goes on and she is complaining of nause, abd pain, and seeing "yellow circles". Bleeding, risk for Psychological Needs - increased What are your views, please? Document Scenario 5 Mr. Duncan's wife meets you in the hall asking what she could bring her husband to eat from home, Scenario 1 Ineffective health maintenance Document results, Educational Needs: Increased acuity Safety- Document and accompany pt to ICU immediately, and handoff report to receiving ICU nurse, Educational Needs: Increased acuity Learn vocabulary, terms, and more with flashcards, games, and other study tools. You now arrive in the recovery unit one hour post-surgery and you are told that the surgery went well.

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