Swift River Simulation - Adult Medical Surgical - Ann Rails

0800 The nurse enters the client's room and introduces themself. The nurse notices the client is crying. The nurse questions the client about why they are crying. The client states, "Everything in my life is just so messed up, and my back is hurting again." Which of the following actions should the nurse prioritize? (Select all that apply.) Ask the client to rate their pain on a 0 to 10 pain scale Check the client's MAR to determine if pain medication can be administered Offer the client comfort through therapeutic communication Continue with a complete head-to-toe assessment of the client Ask the client why she has not been eating or drinking since admission Re-position the client for comfort Reinforce to the client to call for assistance before getting out of bed

Ask the client to rate their pain on a 0 to 10 pain scale Check the client's MAR to determine if pain medication can be administered Offer the client comfort through therapeutic communication Re-position the client for comfort Reinforce to the client to call for assistance before getting out of bed

Ann Rails 24 years old, admitted for back pain. The injury, according to her report, occurred as a result of a domestic dispute in which she was pushed into a kitchen counter. She has no other significant medical history. No known allergies (NKA). Her last vital signs are blood pressure 124/82, temperature 98.2, pulse 84, respiration rate 22, SpO2 96% on room air. She states she has had pain and numbness in her legs for one week. There is abnormal left leg weakness, gait unsteady, 5/10 on numeric pain scale. She is receiving Lortab 2 tabs every 6 hours, which she states relieves her pain. Her neuro assessment is within expected parameters, except for the leg pain upon movement. Activity as tolerated with assistance; we have asked her to call for assistance when getting out of bed. She is on a regular diet, but she has had very little intake since she has been here. Her children have visited, but we have not seen her partner since her admission. She has not made any further comment about them, other than her statement on admission that they caused her injury that she is afraid to go home. Discharge plan: decrease pain and restore normal gait. She is a patient of Dr. Suculo. After receiv

Maslow's Hierarchy of Needs - High Priority Airway, Breathing, Circulation - Low Priority Safety and Risk Reduction - High Priority Urgent vs Non-urgent - Low Priority Chronic vs Acute/Stable vs Unstable - Low Priority

1115 The nurse places a call to the provider to update them on the client. While waiting for a call-back from the provider, the nurse checks on the client and obtains another set of vital signs. The client reports a pain level of 8 on a pain scale of 0 to 10. The nurse informs the client that it is too early for their pain medication to be administered but a call has been placed to the provider to report their pain level. The nurse repositions the client and places a pillow under their knees for better comfort. Which of the following information is the priority for the nurse to provide to the provider? (Select all that apply.) Client's current vital signs Creatinine level BUN level Urinalysis Information regarding client's fall Potassium level Current pain level Sodium level

Client's current vital signs Urinalysis Information regarding client's fall Current pain level Sodium level

0930 The provider is in to see the client. The nurse gives an update based on their assessment of the client. Which of the following prescriptions should the nurse anticipate from the provider? (Select all that apply.) Consult case manager Suicide precautions I & O daily Vital signs every 1 hr Basic metabolic profile (BMP) Consult physical therapy (PT) Decussate sodium Urinalysis

Consult case manager I & O daily Basic metabolic profile (BMP) Consult physical therapy (PT) Decussate sodium Urinalysis

0845 Following administration of the pain medication at 0815, the nurse enters the client's room to check their pain level and perform an assessment. The client has a flat affect but is no longer crying. The client's report of pain at 0800 was 8 on a pain scale of 0 to 10, now they rate their pain at 3. The nurse obtains the client's vital signs, which are Temp 98.9F, BP 128/82, P 77, RR 18, SpO2 96% on room air. The client is oriented x 4, answers questions appropriately, and follows simple commands; moves upper extremities without difficulty, reports pain on moving lower extremities. S1S2 on auscultation, heart beat regular; pulses to all extremities +3; no edema noted, capillary refill < 2 seconds. Respirations even, unlabored. Chest clear throughout all lung fields. Client reports shortness of breath occurs with movement and ambulation due to back and leg pain. Abdomen nondistended, nontender, with bowel sounds hypoactive in 4 quadrants. Client states last bowel movement was "several days ago. I haven't been eating much." Client reports voiding less frequently than usual, states "I haven't been drinking much either." Clients reports urine is amber and "more concentrated than usual."

Nutritional intake Urine output Source of injury Last bowel movement

1100 The nurse is reviewing the client's laboratory results which include the following: BMP: Sodium: 146 mEq/L (Reference range: 136-145 mEq/L) Potassium: 4 mEq/L (Reference range: 3.5 mEq/L-5 mEq/L) BUN: 22 mg/dL (Reference range: 10 mg/dL - 20 mg/dL) Creatinine: .08 mg/dL (Reference range: 0.5 mg/dL - 1 mg/dL) Glucose: 68 mg/dL (Reference range: 74 mg/dL - 106 mg/dL) Urinalysis: Appearance: clear (Reference range: clear) Color: dark amber (Reference range: amber yellow) Odor: aromatic (Reference range: aromatic) pH: 4.2 (Reference range: 4.6 - 8) Specific gravity: 1.001 (Reference range: 1.005 to 1.03) WBC casts: none (Reference range: none) RBC casts: none: (Reference range: none) The nurse is urgently called to the client's room by assisted personnel (AP). The nurse enters the room and finds the client on the floor. The client is crying and states "I thought I could go to the bathroom by myself, and my leg gave out. Now my back hurts more than it did before." Which of the following actions should the nurse take? (Select all that apply.) Perform cranial nerve assessment Initiate a peripheral IV Prepare an incident report Take the client's vital

Prepare an incident report Take the client's vital signs Notify the provider Assess the client's body for injuries

Initial Nursing Assessment 0745: The nurse reviews the information received in report. Which of the following concerns should the nurse address while providing client care? (Select all that apply.) Safety: Injury Prevention Physiological: Mobility Physiological: Pain Physiological: Sensory Physiological: Nutrition Physiological: Elimination Safety: Self-harm Physiological: Thermoregulation

Safety: Injury Prevention Physiological: Mobility Physiological: Pain Physiological: Sensory