Swift River: Fundamentals
Kathy Gestalt Scenario 3 30 minutes later, the patient now rates her pain 7/10.
(pain medication should work within 15 minutes if PO) Administer narcotic pain medication Check vital signs before administering medication Ask the patient what her pain goal is
Joyce Workman Room 306 Joyce Workman, a 42-year-old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. She has been documented as being obese, new-onset hypertension, polyuria, and a rash on her abdomen. She was asymptomatic upon arrival. She was admitted yesterday for stabilization of her glucose levels and to assist her with lifestyle modification. She states she leads a sedentary lifestyle as a bank officer. Her HbA1C is 10%.
Acid-base (high BG) Fluid and electrolytes Metabolism Nutrition
Donald Lyles Scenario 3 You smell smoke when you enter the room and find that the patients' trash can is on fire at his bedside.
Activate fire alarm Contain the fire Assist patient in leaving the room
Kenny Barrett Room 302 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.
Addiction Perfusion
Dotty Hamilton Scenario 2 The patient provides a copy of the advance directive from another state that is six years old. The patient has had significant health changes.
Advise the patient to speak with the appropriate department as her advance directive needs to be current for this state Ask the patient if she has reviewed her advance directive recently
Linda Yu Room 301 Linda Yu, was admitted to your unit after surgery on her left hip due to a fall. She is 2 days post-op. She is 85 years old and has a history of osteoarthritis and cataracts. PT has been getting the patient up with a walker and she is able to take a few steps. She is aware of herself and the situation, but no time or day. She is also anxious as a result of recent surgery. Her family lives out of state, but the daughter was here for the surgery, she left yesterday. The plan is to discharge Ms. Yu back to her assisted living facility. Her daily medications at home include: Prednisone 5 mg, Furosemide 20 mg, and ASA 81 mg daily. The surgeon added oxycodone 5mg q 4-6 hours prn pain. NKDA.
Anxiety Care coordination Stress and coping
Jody Rush Room 301 Jody Rush, 20 y/o female, admitted for right femur fracture status post skiing accident. She is in a traction splint and will be going for surgical repair today. Vital signs are BP: 120/62, P:88, R: 20, T: 98.9 F, 37.2 C, PaO2: 99. She has been in a lot of pain, and has been receiving 25 mcg IVP, q2 hours Fentanyl for pain. She was nauseated after her last Fentanyl dose, and the Provider ordered an additional 4mg IVP, Zofran. She has a history of exercise induced asthma, and uses a rescue inhaler, Albuterol. Her parents are on their way; they are flying in today. She was on a ski trip with some of her friends from college; her best friend has been camped out with her. We were able to get her on a bed pan earlier, but it took a lot of work. We just received an order for a foley catheter. There was some concern that she may have sustained a head injury as she has an abrasion to her forehead. She denies ever losing consciousness. Patients affected extremity has normal pulses, and the capillary refill is less than 3 seconds.
Anxiety Gas exchange Perfusion, risk for
Dotty Hamilton Room 302 Dotty Hamilton 52 y/o female who has been admitted for bariatric surgery. She has arrived at 0600 and is scheduled for a laparoscopic Roux-en-Y gastric bypass (RYGB). She is super morbidly obese with a BMI of 52, Ht, 5'3", Wt, 293lbs. She has well-controlled hypertension with Losartan (Cozaar) 50 mg q daily. She also takes Metformin to control her Type 2 Diabetes. She has sleep apnea, and she brought her CPAP machine. She is very excited about the surgery but is also apprehensive. A friend told her that the complication rate for this surgery is very high. She believes this surgery is her only hope, as she says she has tried everything else to lose weight. Her husband is with her and seems to be very supportive. Body Mass Index (BMI) = kg/m2, where kg is a person's weight in kilograms and m2 is their height in meters squared. A BMI of 25.0 or more is overweight, while the healthy range is 18.5 to 24.9. Example: Weight = 133.18 kg, Height = 160.02 cm (1.60 m) Calculation: 133.18 ÷ (1.60)2 = 52
Anxiety Glucose regulation Nutrition
Linda Yu Scenario 4 Ms. Yu has been sleeping a lot during the day after receiving her pain medication. Your concerned about patient's current sleep pattern and are performing a sleep assessment.
Ask Ms. Yu if what sleep aids she takes at home Ask patient how well she sleeps at night when at home Assess patient's anxiety/depression related to sleep deprivation Review time/dose of patient's pain medication
Dotty Hamilton Scenario 1 Mrs. Hamilton is excited about her surgery. During the admission process, you ask the patient if she has an advance directive; she answers yes.
Ask for a copy of the advance directive Ask the patient when the advance directive was last updated
Preston Wright Scenario 3 When reminding the patient to avoid pressure on his heel and sacrum, you notice he has become confused and is cognitively impaired. What are some communication skills to assist with a cognitively impaired patient?
Ask one question at a time Use simple sentences and avoid lengthy explanations Use charismatic language Include family and friends in conversations
Kathy Gestalt Scenario 1 You enter the patient's room in response to a call light; Kathy is complaining of pain.
Ask the patient to rate her pain on a scale of 1-10 Check to see the last time the patient received pain medication Ask the patient what has made the pain better?
Tim Jones Scenario 1 The nurse is assessing the patient as to where the patient's injuries originated from. To do so, the patient must be assessed for delirium, depression, or dementia. What are your next steps?
Assess patient's ability to perform activities of daily living over the last 6 weeks Determine onset of confusion Administer a mini-mental state exam
Dotty Hamilton Scenario 5 The patient arrests the next day under the care of another nurse; a code blue is initiated. You recognize the patient and assisted her yesterday; you are aware that the advance directive states no intubation and no CPR.
Check the chart for the presence of a DNR order to provide the code team Provide emotional support for the patient`s husband Inform the team that the patient has an advance directive to include no intubation and no CPR
Preston Wright Room 307 Preston Wright, 73-year-old male patient of Dr. Greene, status post CVA 4 weeks ago. He has been readmitted for a red spot on his sacrum of 1 cm and a 2 cm blister on his right heel. IV fluids of D5 1/2 NS are infusing at 100 mL/hour to his right forearm. Mr. Wright is pleasant and cooperative but needs to be reminded to avoid pressure on his heel and sacrum. Post CVA, he has developed some aphasia and is having difficulty with verbal communication. He has orders for dressing changes q daily and pain medications before the dressing change.
Cognition Communication Mobility Sensory perception
John Wiggins Room 304 John Wiggins, age 36, has been admitted for a possible concussion from an ATV rollover without a helmet three days ago. He is alert and cooperative but does complain of a consistent headache and nausea. Upon admission, he had a blood-alcohol level of 0.09. His vital signs are normal and are being taken with Neuro checks q 2 hours. His Glasgow coma scale is 15. He admits to drinking a 6-pack of beer a day.
Cognition Functional ability Intracranial regulation Sensory perception
Don Johnson Room 308 Don Johnson, There was a warehouse fire that quickly spread to an adjoining neighborhood. Multiple burn injuries have overwhelmed the local hospitals. The ICU and burn unit are full of the most severe patients, so some of the patients have been admitted to the stepdown unit on the med-surg floor. Don Johnson 23 y/o male was injured when trying to rescue a coworker. He has sustained burns over part of his back, to include his right arm and right side of his face. Most of the burns are superficial and partial thickness with a few small areas that may be full thickness. The patients beard caught on fire causing burns on the right of face including his right ear. He has an 18-gauge IV to left AC and the Parkland fluid resuscitation is ordered. The patients weighs 90 KG. 4ml x 90 x 20. He is on simple face mask patient has facial burns and may or may not be able to use a mask so this may be questioned and has a dry cough. Vital signs are BP: 140/82, P: 112, R: 24, T: 99.2 F, 37.3 C, PaO2: 98%
Comfort Fluid & electrolytes Functional ability Nutrition Thermoregulation
Karen Cole Room 303 Karen Cole, 56-year-old female, a school principal at White House High School. Admitted directly from the Dr.'s office to the IMCU after an initial complaint of tightness in her chest, denies pain and slight shortness of breath. The patient has a history of cardiovascular disease. Vital signs are BP: 168/92, P: 90, R: 24, T: 98.6. Her husband insisted that she come. She insists that she will only stay 12 hours because she has to be back to school in the morning.
Comfort Gas exchange Perfusion
Mary Barkley Room 307 Mary Barkley, 74y/o female has been admitted to your floor with a respiratory infection and she has tested positive for COVID-19. She resides in an assisted living facility which has seen four deaths related to COVID-19. She is exhibiting the same initial signs and symptoms as the other patients and her primary care provider would like to start aggressively treating her. She is running a low-grade fever of 99.8 F, SpO2 91%, and has a sore scratchy throat which is causing an unproductive cough. She also is complaining of chills, muscle pain and headache. She is an at-risk patient because of her age. She also suffers from Lupus and is already taking Hydroxychloroquine, a first-line lupus therapy, but there is no conclusive evidence of its benefits for coronavirus yet. She is very fearful and is requesting to see her family. She states that she does not want to die alone.
Comfort Grief/loss Oxygenation
Roger Clinton Room 303 Roger Clinton, 57-year-old male construction worker arrives at 0600 to be prepared for a partial thyroidectomy to determine if he has cancer. His past symptoms for three months have been that he noticed a slight hoarseness in speaking, a slight dry cough not related to a cold, and upon examination had a "pea-size" lump on the center of his neck. His Endocrinologist had a radioiodine scan performed that showed a suspicious area. The plan is to obtain a biopsy from several areas of the thyroid gland, and hopefully to leave as much as possible in place. Roger knows that it will take three days after surgery to determine if he has cancer but does not understand the implications resulting from a thyroidectomy. (Lifetime thyroid replacement medication.)
Comfort Metabolism Patient Education Perfusion
Donald Lyles Scenario 5 You are completing a documentation for Mr. Lyles fall, and preparing him for an x-ray.
Complete an incident report and submit to risk management Document in nurses' notes fall event and patient status
Karen Cole Scenario 3 You notice the patient's pulse ox is low on the left index finger. While assessing the apical radial pulse, you find the pulse to be abnormal
Consider warming the patient's hands to get an accurate reading Switch pulse ox to the right hand Ensure there is no fingernail polish on the pulse ox Check the pulse ox on your finger
Roger Clinton Scenario 4 Mr. Clinton has been experiencing more and more that his pain is increasing. He is now complaining of nausea. You are concerned that this may be anxiety as a result of his recent diagnosis of malignancy.
Contact Provider for an anxiolytic medication Reassess wound site Initiate alternative distractions for pain / anxiety interventions
Charlie Raymond Scenario 4 The patient has been taking furosemide (Lasix) and is making frequent trips to the bathroom to urinate. He is found in the bathroom and does not have his O2 on.
Contact respiratory therapy to see about longer O2 tubing or portable tank Provide the patient a urinal as an alternative Remind the patient he must keep his O2 on at all times
Ann Rails Scenario 4 The nurse is performing a Subjective, Objective, Assessment, Plan (SOAP) note. You have identified several nursing diagnosis and concerns. Throughout the shift, implement a plan of action. Please select Plan information to document.
Contact social services Provide therapeutic communication and emotional support to the patient Reassess patients pain every time PRN medication is due
Roger Clinton Scenario 2 You review Mr. Clinton's pathology report. The report indicates the presence of a malignancy/thyroid cancer. You re-enter the patient's room and he asks you directly if his pathology report has come back
Contact the Provider to tell them the patients pathology report has returned, and Mr. Clinton is anxious to know the findings of his pathology report Tell the patient that it has come back, and his Provider will discuss the findings
Dotty Hamilton Scenario 3 Mrs. Hamilton has had her Roux-en-Y gastric bypass (RYGB). 4 days post-op, she is very ill. The patients ask about her advance directive; check to see the status of the updated advance directive.
Contact the appropriate department to see the status of the advance directive Check the chart for the updated advance directive
Tim Jones Room 302 Tim Jones, an 82-year-old male patient of Dr. Diggs, just arrived to the ER from home. He was confused upon arrival. During the initial assessment, fresh and various bruise healing stages were noted to his shoulders, lower back, ribs, and thighs. Admitted to Med-Surg for new-onset confusion. Mr. Jones is guarded and has facial grimacing anytime someone reaches toward him or touches him. He does moan when rolled.
Coping Family dynamics Functional ability Tissue integrity
Ann Rails Room 308 Ms. Rails has bruises to her right forearm and face. She complains of back pain 6/10 pain scale. She was medicated with hydrocodone 5 mg PO two hours ago. Her vital signs are BP: 110/60, P: 74, R: 20, PaO2: 98%, T: 98.6 F, 37 C. Ms. Rails has told you that she is concerned about returning home and is afraid her boyfriend will return. She also expressed concern about finding a new job
Coping Interpersonal Violence Mobility Safety
Kenny Barrett 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"?
Current elevated BP State patients name and date of birth
Wight Goodman Scenario 3 In the elevator, you run into a chaplain from a local church. He asks you, "Is Wight Goodman here? I heard he was injured playing softball and wanted to come by and check in on him. He's always been the best player on our church's softball team! How's he doing?"
Direct Chaplain to the visitor desk Tell the patient that the Chaplain from his church was looking for him, and is at the visitor desk Explain to Chaplain that you cannot discuss patients who are admitted or not admitted to the hospital
Charlie Raymond Scenario 2 Mr. Raymond is found walking down the hallway without a mask. He is confused to person, place, and time.
Direct Mr. Raymond back to his room and place his O2 cannula Assess Mr. Raymond's A&O x4 and pulse oximetry Give Mr. Raymond a mask
Donald Lyles Scenario 1 You are administering Insulin for Mr. Lyles. What do you do with the needle immediately after injecting the patient?
Dispose syringe in sharps container Engage Safety
Wight Goodman Scenario 2 The patient's boss calls you asking, "How is Wight doing? When do you think he will be able to return to work?"
Do not give out any information without consent from the patient Explain HIPAA policy to the patient's boss Explain to Mr. Goodman that his boss called for an update, and you could not give out any information, but he may want to call him
John Wiggins Scenario 2 Upon examination, you found that the patient's pupillary were not equal bilaterally.
Document size and reaction time of each pupil Ask the patient if a healthcare provider has noted unequal pupils before Notify the healthcare provider of finding immediately
Kenny Barrett 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?
Educate UAP regarding notification of abnormal range of vital signs Reassess blood pressure and pulse
John Wiggins Scenario 5 You have reported the decreased Glasgow Coma Scale to the Provider. They are on their way in. Select appropriate interventions in the meantime.
Ensure side rails are up and the bed is in the lowest position Ensure patient is NPO untiled advised otherwise Provide one-to-one care until the Provider arrives Elevate the head of the bed 30 degrees
Preston Wright Scenario 2 Mr. Wright did not bring his hearing aids to the hospital. Select appropriate interventions to assist.
Ensure you have the patient's full attention before speaking Face patient with mouth visible while speaking Reduce environmental noise
Linda Yu Scenario 3 You have orders to take labs, vital signs, check IV pump and hang antibiotics, and turn the patient. You requested lab come at 5am, but they are now here at 4am and the patient is still sleeping.
Enter patient's room quietly Obtain vital signs and turn patient during lab draw Check IV pump and hang antibiotics while patient is sleeping
Linda Yu Scenario 1 When making patient rounds at 10pm, you enter Ms. Yu's room and she is sleeping. Ms. Yu's vital signs have been stable throughout her post-op period.
Enter room quietly Observe breathing pattern Ensure call light is in reach
Charlie Raymond Scenario 1 Inform Mr. Raymond's family members that they will not be allowed to visit him while he is here, that they must self-isolate and _____________.
Explain to the patient and family the need for a negative pressure room Inform family members that they need to be tested for COVID-19 Suggest that the family Facetime/video chat
Linda Pittmon Room 305 Linda Pittmon isa 74-year-old female patient who is a noncompliant diabetic and frequently stays at the local homeless shelter. She has been admitted to the floor with complaints of numbness in her right foot and ankle. Mrs. Pittmon states she has had numbness for years, but "now I can't feel it at all, and my toes don't look the right color.". What screenings and assessments should you antipate needing?
Fluid & electrolytes Nutrition Perfusion Sensory perception Tissue integrity
Charlie Raymond Room 305 Charlie Raymond, 65-year-old male who was admitted to a negative pressure room on Med-Surg for COVID precautions. He has a history of COPD, hypertension, diabetes type II, and a recent myocardial infarction. He is a retired postal worker who lives at home with his wife. He is on Claforan (cefotaxime) 2 g IV BID hr and sliding scale insulin. Initially this cardiologist was concerned about congestive heart failure and Mr. Raymond is receiving Furosemide (Lasix) 20 mg IV twice a day for pulmonary edema. Vital Signs: BP is 145/78, Pulse 89 Respirations 24 and slightly labored, Temperature 100.2 SaO2 94% on 2L nasal cannula. The patient/family is fearing the worst due to COVID-19 Pandemic.
Gas exchange Infection Perfusion Metabolism (diabetes)
Hildegard Lowe Room 304 Hildegard Lowe, 68 y/o female, newly admitted after a rough night in the ER after coughing for the last 2 months. Patient is alert and cooperative, visually limited and declining. She is on Oxygen at 2L. She has an IV 0.9 normal saline, 125 an hour. Chest x-ray upon admission showed right middle lobe pneumonia. Vital signs are BP: 128/86, P: 105, R: 32, T: 99.8 F, 37.7 C, SaO2: 93%. Plan of care is antibiotic therapy, incentive spirometry, O2 supplementation, and pending labs and blood cultures from the ER. Patient is receiving Rocephin and received Zithromax in the ER. Patient does have a history of Granulomatosis with Polyangiitis but has been stable for 5 years w/o treatment. She is widowed and came to us from the retirement community. She has one daughter who is on her way from out of state; she will be arriving sometime today. Patient states she is allergic to mangos.
Gas exchange Infection Sensory perception (visually impaired)
Kenny Barrett Scenario 4 In continuing with the SBAR, what should be included in the "A"?
Give current vital signs Patient is complaining of a headache and dizziness
Donald Lyles Room 306 Donald Lyles, 52-year old male, was admitted yesterday evening for stabilization of his uncontrolled type II diabetes. His HbgA1c is 10.6%. He has a history of a Myocardial Infarction, MI, one year ago, and has refused all cardiac rehab, and has not had another cardiac event. He refuses to comply with dietary recommendations. His BMI is 37. Vital signs are BP: 146/94, P: 88, R: 22, T: 99.2, PaO2: 94% Blood glucose upon admission is 340 mg/dl
Glucose regulation Nutrition Safety (BMI, high BG)
Tim Jones Scenario 3 In an older adult, multiple skin changes happen with aging. Identify possible wounds of abuse as opposed to areas of normal aging. Select wounds that are not a result of aging.
Hand imprint on the arm Multiple bruises to the back
Karen Cole Scenario 2 The patient's systolic blood pressure (BP) is 30 mmHg lower in the left arm than it is in the right.
Have a nursing colleague verify BP readings Have the patient rest in the same position and repeat BP assessment in 15 minutes Notify Healthcare Provider of findings
John Wiggins Scenario 3 After notifying the healthcare provider of your findings, you return to the room to reassess Mr. Wiggins. You find that he has become drowsy and slightly confused. Perform a Mini-Mental State Examination
Have patient identify name/object you are holding Assess patient`s orientation to time and date Have the patient listen carefully to 3 words and repeat them to you
Preston Wright Scenario 4 The patient is being prepared for discharge but cannot find his glasses. What actions are appropriate to take next?
Help patient search for his glasses Identify yourself verbally when entering and leaving the room Do not rely on gestures or non-verbal communication Use indirect lighting to avoid glare
Linda Pittmon Scenario 1 The patient presents to the unit with c/o numbness in the right foot and ankle and toes "not looking the right color." All 5 toes on the right foot are necrotic, absent pedal pulses, skin cold to touch, appearance dry, cracked, and black up to mid-calf. Foul odor noted with green drainage coming from toenail beds. The provider is concerned that the patient may be septic. What can you anticipate the patient's needs will be?
IV fluid challenge/bolus Wound Cultures Blood Cultures IV Antibiotics
Wight Goodman Scenario 1 Mr. Goodman's girlfriend calls the nurses station asking, "What time is his surgery and how is he doing?"
Inform Mr. Goodman that his girlfriend called about his status. Explain HIPAA policy to the girlfriend Do not give out any information without consent from the patient
Linda Yu Scenario 2 Ms. Yu calls the nurse at 12am requesting assistance to the bedside commode. This is your first night taking care of Ms. Yu and you are not sure how well she does transferring to the commode.
Inform patient that you will turn on the light Ensure bed is in the lowest position and the bedside commode is next to the bed Have patient sit on edge of the bed and place gait belt around waist Call for 2nd assistance, if needed
Roger Clinton Scenario 3 The Provider tells the patient they are going to go back to surgery and complete a total thyroidectomy. Mr. Clinton is made aware that because of the nature of the malignancy, they must perform lymph node biopsies. The patient is now extremely anxious and asks you several questions including: "With the treatment, what side effects will I experience? Am I going to need chemo? What about radiation? What are my survival chances?"
Inform the patient that there are many successful treatment options Inform the patient that he will have plenty of time to decide, and the Provider will discuss all the options with you
Kathy Gestalt Scenario 2 Ms. Gestalt rated her pain 4/10. The next PRN medication is not due for 30 minutes. The nurse implements non-pharmacological pain relief measures:
Inspect toes on cast site for temperature, blanching, and pulses Offer distraction (TV, book, etc.) Reposition patient to a more comfortable position
Wight Goodman Room 301 Wight Goodman, Patient was admitted to the floor last night from the ER for an orbital fracture. He was hit in the left eye by a softball yesterday. Apparently, he was pitching, and the batter hit a line drive hitting him in the right side of the face. They applied some ice to his face, and he decided to go to the post game keg party instead of coming to the ER. The patient stated that there was significant swelling, but his vision was fine, and the pain was controlled with beer and 800mg of ibuprofen. He was unable to sleep later in the evening as the pain became worse, and his vision became more impaired. The maxillofacial surgeon was consulted, and they will see him this morning. They were not concerned as his intraocular pressure was normal in the ER. There is significant edema and discoloration to the left side of his face, and his left eye is almost completely swollen shut. His visual acuity is diminished, and the whites of his eyes are hemorrhaged. His pain has been well controlled with IV morphine 4 mg, written every 3 hours. He has a 20ga saline lock to his right hand, that was started in the ER. He has no other health concerns. He's being admitted for pain control, close observation of his intralocular pressure, and head injury.
Intracranial Regulation Mobility Sensory
Roger Clinton Scenario 1 Mr. Clinton is awaiting the pathology report. He is experiencing pain and a scratchy throat postoperatively. The dressing is intact with minimal pinkish drainage.
Listen to patient's concern Rate patient's pain on a scale of 1-10 Assess his airway Determine if drainage is increasing
Kathy Gestalt Room 303 Kathy Gestalt, 33yr-old, Dx- second-day post-op open right Tibia/Fibula fracture, plaster cast in place on the right lower leg. No known allergies. Vital signs -Temp 98.4, BP 116/76, P 96, RR 20, SaO2 99%. Neuro WNL, alert and cooperative but worried about scarring and is reluctant regarding walking on leg. Diet as tolerated, up ad-lib after gait training. Crutches at bedside adjusted for height. Dr. Anderson
Mobility Pain Safety (cast, crutches)
Tim Jones Scenario 5 After finishing the admission assessment. What are the necessary actions to be incorporated into the plan of care?
Notify HCP of suspected abuse Report suspicion of abuse to adult protective services Have nursing personnel in the room when family visit
Roger Clinton Scenario 5 The family has been calling to seek information about the patient's diagnosis. You have spoken to several family members today. The wife is inquiring if he should be transferred to a major Cancer Treatment Center?
Notify the Provider of the patient and family's inquiry on next steps Inform the wife that family members have been calling all day long, and that it would be appropriate for her to be designated as the point of contact for Mr. Clinton" should be "Ask the patient if he would like to designate a point of contact for the family"
Linda Pittmon Scenario 3 The Vancomycin has been discontinued, and Mefoxin has been started. The patient has become more confused. The patient is fidgety and is observed picking at her skin and clothes. The patient states, "I am sick to my stomach and feel like I have bugs crawling all over me!!!" What should the nurse do?
Notify the physician that the patient may be suffering from alcohol withdrawal. Check her blood glucose
Ann Rails Scenario 3 The nurse is performing a Subjective, Objective, Assessment, Plan (SOAP) note. Ms. Rails has bruises to her right forearm and face. She complains of back pain 6/10 pain scale. She was medicated with hydrocodone 5 mg PO two hours ago. Her vital signs are BP: 110/60, P: 74, R: 20, PaO2: 98%, T: 98.6 F, 37 C. The patient appears anxious. Ms. Rails has told you that she is concerned about returning home and is afraid her boyfriend will return. She also expressed concern about finding a new job. Please select Assessment information to document.
Nursing concern/diagnosis of acute anxiety Nursing concern/diagnosis of patient safety related to domestic abuse
Karen Cole Scenario 4 The patient has become anxious about their pain, and their respiratory rate is 26.
Observe the degree of chest wall movement while counting the rate and palpate the chest wall excursion Observe the complete respiratory cycle Auscultate the lungs
Donald Lyles Scenario 4 Mr. Lyles falls while evacuating the room in the hallway
Obtain vital signs Notify HCP of fall Assess for obvious injury
Dotty Hamilton Scenario 4 You are informed that the advance directive was not completed. The patient has deteriorated but can communicate. The husband is asking, "Can we complete one now?"
Offer to assist in completing an advance directive Inform healthcare provider that the advance directive was not completed, but one is being executed now Obtain witnesses to sign an advance directive
Ann Rails Scenario 1 The nurse is performing a Subjective, Objective, Assessment, Plan (SOAP) note. Ms. Rails has bruises to her right forearm and face. She complains of back pain 6/10 pain scale. She was medicated with hydrocodone 5 mg PO two hours ago. Her vital signs are BP: 110/60, P: 74, R: 20, PaO2: 98%, T: 98.6 F, 37 C. Ms. Rails has told you that she is concerned about returning home and is afraid her boyfriend will return. She also expressed concern about finding a new job. Please select subjective information to document.
Patient's concern about going home and finding a job Pain assessment
Ann Rails Scenario 2 The nurse is performing a Subjective, Objective, Assessment, Plan (SOAP) note. Ms. Rails has bruises to her right forearm and face. She complains of back pain 6/10 pain scale. She was medicated with hydrocodone 5 mg PO two hours ago. Her vital signs are BP: 140/80, P: 74, R: 20, PaO2: 98%, T: 98.6 F, 37 C. She is restless and her BP and pulse have increased. Ms. Rails has told you that she is concerned about returning home and is afraid her boyfriend will return. She also expressed concern about finding a new job. Please select objective information to document.
Patient's vital sign Color/size of bruises on the patient's face and right forearm Recent medication dose The patient's restlessness and changes in BP and pulse
Linda Yu Scenario 5 Request PureWick catheter so patient's sleep is not disrupted by voiding during the night. Adjust comfort measures for Ms. Yu prior to sleep, and ensure she receives pain medication on schedule during the night.
Place PureWick catheter Give patient a bed bath and offer a back rub Administer pain medication throughout the night
Tim Jones Scenario 4 The nurse is concerned that the patient may be abused in several ways. The nurse assumes that the prescription medication is being diverted to the son. After going through the patients medications, it is noted that the patient's Tylenol number 3 is missing. When asking who cares for him daily, Mr. Jones notes that his son takes care of his finances and filling his medications. The patient's son and grandson live with him; when the grandson comes into the room, the patient grimaces. Determine the types of abuse.
Psychological abuse Medication abuse Financial abuse
Kenny Barrett Scenario 3 In continuing with the SBAR, what should be included in the "B"?
Reason the patient was admitted Patient has past medical history includes hyperlipidemia History of smoking
Tim Jones Scenario 2 While attempting to inspect the patient's wounds, he is fearful of your physical advances. How will you develop a sense of trust with the patient?
Reduce external stimuli Sit at the patient's eye level and ensure they can see your lip movement and facial expression Speak slowly in a normal tone of voice Sit quietly with the patient allowing them enough time to respond
Kenny Barrett Scenario 5 In continuing with the SBAR, what should be included in the "R"?
Request for change in IV rate from 125mL/hr. to 50mL/hr. Suggest/ask for an anti-hypertensive medication
Wight Goodman Scenario 5 Mr. Goodman is meeting in his room with his attorney. He requests copies of his medical records to give to his attorney.
Request form from medical records for patient release of information Inform Mr. Goodman that he must fill out a form requesting the medical records Inform Mr. Goodman that you are not allowed to print records
Charlie Raymond Scenario 5 The patient's wife shares with you her concerns that, should he survive COVID, when she leaves her husband alone, he is going to sneak a cigarette while using oxygen.
Smoking while using oxygen will be part of discharged teaching, and followed up by the home health nurse Reassure wife that the Mr. Raymond is doing well, and we expect him to recover Relay the wife's concerns to the discharge planning team
Wight Goodman Scenario 4 In the cafeteria, you overhear two nursing students discussing Mr. Goodman's condition, and making comments about his present girlfriend. One of the students says, "I've been out with him one time; he is so cute!"
Stop the conversation immediately Remind students of HIPAA policy, and report observations to the Nursing professor Inform students that it is inappropriate to discuss relationships that you have had with patients.
Linda Pittmon Scenario 2 The nurse has started the IV antibiotics (Vancomycin). The patient is anxious, has developed hives, and has become more hypotensive. What actions should the nurse take next?
Stop the infusion Notify the provider after stopping the infusion
Karen Cole Scenario 1 When taking the patient's vital signs, you notice Mrs. Cole BP in her left arm is significantly lower than what was initially reported.
Take her BP in both her arms If concerned about the accuracy, take BP with a manual cuff Assess radial and apical pulse for 60 seconds Explanation: Inflating above the systolic should be inflated to a maximum of 20mL/hg
Linda Pittmon Scenario 5 The day after surgery, Ms. Pittmon is very angry that her leg was removed without her consent. She is alert and oriented and recovering well. Her Blood glucose is 100, her white count is normal. Her BP is 110/60, HR 89, Resp 16, and Temp 98.9. Her dressing needs to be changed, but she won't let the nurse perform a dressing change. She tells the nurse that she is going to sue the hospital. What actions should the nurse take with this patient.
Tell the patient that dressing must be changed Use therapeutic communication to convey empathy Notify HCP and nursing supervisor
John Wiggins Scenario 4 Mr. Wiggins's level of consciousness has deteriorated throughout the day. During his initial assessment, his Glasgow Coma Scale was 15. The healthcare provider asks what his current Glasgow Coma Scale is, you report his Glasgow Coma Scale is now 11. What part(s) of the GCS should be included?
The patient opens his eyes to speech The patient is confused and/or uses inappropriate words The patient has difficulty obeying commands but localizes pain
John Wiggins Scenario 1 You are gathering supplies to complete an initial neurological assessment on Mr. Wiggins.
Tongue blade Cotton swab Stethoscope Penlight
Karen Cole Scenario 5 Mrs. Cole complains of being hot and uncomfortable. Because of the patient's shortness of breath, she cannot hold the thermometer to complete an accurate reading.
Use a temporal or tympanic thermometer, if available Take an axillary temperature with the blue electronic thermometer (red for rectal)
Preston Wright Scenario 5 The nurse is having difficulty communicating the discharge instructions with Mr. Wright's wife. Mrs. Wright is Korean and speaks very little English. What are appropriate actions to take in communicating with Mrs. Wright?
Use an interrupter/ family member if available Access telephone language line Use a communication board, if available Speak to Mrs. Wright in a normal tone and cadence
Preston Wright Scenario 1 Mr. Wright is experiencing aphasia. Select the appropriate ways to facilitate communication with him.
Use visual cues Listen attentively and be patient Let the patient know if you did not understand him Ask simple questions that require yes or no answers
Donald Lyles Scenario 2 You are completing a glucose check for Mr. Lyles using a glucometer. Previous blood glucose has been averaging 185 mg/dl every morning.
Verify patient identity Use unexpired glucometer strips
Charlie Raymond Scenario 3 Mr. Raymond's pulse ox is 88% after returning him to his room and connecting him to nasal cannula.
Wait 2-5 minutes and re-take patient's pulse ox Ensure O2 tubing is in place and unobstructed Ensure patient is in a semi-recumbent position and at rest
Linda Pittmon Scenario 4 Surgery called to the unit to inform the nurse that Ms. Pittmon has been scheduled at 1300 for a Below the Knee amputation. The patient has become confused and combative and has pulled out her IV. She is a tough IV stick, and it took several attempts previously.The Preop nurse tells the floor nurse to have the patient sign the consent, restart the IV, and anesthesia will see the patient in the preop hold. What actions does the nurse take?
Wait until anesthesia evaluates the patient and have them assist in restarting the IV. Notify anesthesia to come to the floor to evaluate the patient. Have the next of kin sign the operative consent if available.
