MCQ Questions
Q.1.
Education needs increasedfall risk normalhealth change increasedneuro normalpain level normalpsych needs normalScene 2 Nursing Concerns:Psych:Acute pain FALSEchronic pain FALSEImpaired comfort FALSENausea FALSESaftey:Deficient knowledge TRUEgrieving FALSEScene 3Offer patient a urinal and assist to bedside, if neededPerform post-op assessment to include visual inspection of dressings, vital signs, painAssist patient to a comfortable position in bedTell patient not to get out of bed without assistanceEnsure side rails are up and call light is within reachScene 4Assess the large dressing site (full thickness)Administer pain medication as orderedAssess dressing supply needs and obtainAssess patient's need for emotional support and evaluate effectiveness of pain medicationDocument color and amount of wound drainage on dressingScene 5Restart new IVAdminister nausea medicineAssess for contraindications to ChemotherapyWeigh the patient and verify dosageTake VS and provide patient teaching on chemotherapy prior to infusion.Scene 6Complete full assessment and inspect patient's woundsApply clean dressing to all woundsEncourage patient to change body position and not lie on woundsContinue to encourage nutrition and fluidsDocument and inform HCP of wound changesscene 7Assess patients concerns and understanding plan of care and current treatmentTeach patient about the benefits of a picc line with chemotherapeutic agentsMake referral to the infusion clinic to verify appointmentsConsult social services for transportation needsHave patient verbalize understanding of treatment and future needs
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    John Davis, is a 54 y/o male admitted for surgical resection and biopsy of multiple lesions on his back and shoulders. The patient is fair skinned with multiple moles on his shoulders and anterior and posterior torso. The patient is high risk for basal cell carcinoma and has had mole - mapping. Mr. Davis is very thin and reports an 8 lbs. weight loss over the last four months. He owns a land scape business, works outside, he also enjoys being out on his boat. He had a basil cell carcinoma removed from his forehead four years ago (Mohs micrographic surgery) which has left a large scar. Mr. Davis is concerned about potential scars from these lesions. He denies any other health issues. The patient does not smoke, but drinks 2 beers after work daily and more on the weekends. VS BP 150/89, P 62, R 14, T 98.2.Scene 2 Select ConcernsScene 3 The surgery went well, he had one partial thickness lesion on his shoulder and one of the lesions on his back are full thickness that will require staged closure or a possible skin graft. He has a 4x4 dressing on his right shoulder, two large dressings, and two smaller dressings on his back. His vital signs are stable. He has an IV NS to his left hand @ TKO. He received 2 liters intraoperatively. He was given Fentanyl 100 mg and Zofran 4mg in the PACU. The patient asks if he can go to the bathroom because he needs to void immediately.Scene 4The patient has been made aware that he has advanced basal cell carcinoma and has a poor prognosis. The largest dressing is saturated with serous sanguineous fluid. The patient is complaining of 8/10 pain from two of the partial thickness incisions on his back (he will need skin graft soon). Patient states the larger dressings on his back that are full thickness do not hurt at all. The patient has an order for dressing changes PRN. The patient is awaiting orders for chemotherapy. VS BP 162/90, P 99, R 20, T 98.9.Scene 5The nurse's aide reports that the Mr. J did not eat any of his lunch or dinner. The surgeon and oncologist had visited with the patient that morning. When ask the patient about his appetite the patient states that he is nauseated. The SL is occluded. The orders came to initiate Chemotherapy: vismodegib (Erivedge) is 150mg orally daily. The sonidegib (Odomzo) dose is 200 mg orally daily taken on an empty stomach, at least 1 hour before or 2 hours after a meal.Scene 6The nurse is still concerned about the patient's appetite the next day, 3 days post-op. The patient will be seeing an oncologist before his discharge and the surgeon has stated that he will need to have several more lesions removed ASAP. The patient has learned that his cancer is stage 4 basal cell and has metastasized. He has not been ambulating and has been laying on his back most of the time. When changing the dressings, the nurse notices that the one of wounds on his back appears inflamed and reddened as well. VS BP 150/80, P 82, R 14, T 100.8Scene 7The doctor has chosen to pursue a more aggressive chemotherapy agent related to metastasizing cancer and side effects (muscle cramps and gastrointestinal discomfort). The patient will continue chemotherapy after discharge and is being counseled for the placement of a peripherally inserted central catheter (PICC) and why he needs it. The patient will be receiving his chemotherapy from an outpatient infusion clinic. The patient is still not eating and seems complacent in his care. When inquiring about his support system the patient states that running a business does not allow much time for friends or family.
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    Mary Barkley, 74y/o female has been admitted to your floor with a respiratory infection and she has tested positive for COVID19. She resides in an assisted living facility which has seen four deaths related to COVID19. 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 99.8 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.Scene 2, Nursing ConcernsScene 3Have patient verbalize understanding of treatment and future needsScene 4Mrs. Barkley is becoming more adamant about leaving while her physical condition continues to deteriorate. Her Temp is 100.8 BP 100/62 P 92 R 21 SpaO2 91. The nurse auscultates fine crackles in her lungs bilaterally, but her sputum is clear. She is oriented x3 but at times seems to be talking to someone in the room when no one is present. She told the nurse that she does not want a breathing tube, but her family has told the nurse by phone that they want every effort done to save her. She pulled out her IV and it will need to be restarted for her IV cipro dose that is due now. The nurse has another high acuity admission that has just arrived from the ER.Scene 5Ms. Barkley continues to deteriorate and is shouting for her family. She is disoriented and believes the nursing staff is trying to kill her. Her Temp is 101.3, BP 98/58, P 98, R 22, and PaO2 86%. The PCT is requesting to be relieved as the patient keeps pulling at the PCT's mask to see who she is. The nurse calls the attending provider requesting that Ms. Barkley be transferred to the ICU, but there are no rooms available. Instead the nurse is told to put the patient on telemetry and call RT for a CPAP trial.Scene 6The patient continues to be combative while attempting to initiate the CPAP trial. Healthcare provider has ordered Haldol in order to sedate the patient. Vital signs are deteriorating, BP 90/58, P 116, R 28, PaO2 85%, T 102.0 Enter the room after taking vital signs.Scene 7Ms. Barkley requires emergency intubation, and the Healthcare Provider on scene suggests that the patient did not want to be intubated. You, the nurse, are concerned because the family asked for everything to be done and the patient never signed a do not resuscitate order (DNR). The patient has now been sedated, and RT is temporarily maintaining their saturations with effective valve mask ventilation.
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    CCChanthavy Chhet, 46 y/o female admitted for dehydration and gastritis. She is accompanied by her uncle who speaks fluent English, but patient speaks little to no English and is a Cambodian native. The uncle suggests that nursing staff address the patient by CC. Family is concerned that she has not been eating or drinking. Her non-verbal communication indicates abdominal discomfort. Vital signs are: T: 99.4 F, 37.4 C, P:92, R:18, PaO2: 98%, BP: 102/82 sitting, BP: 90/64 standingScene 2: Acuity 3select appropriate concerns based on info:Scene 3: CC's initial admitting orders include starting an IV D5 ½ NS at 100mL an hour, regular diet is tolerated. Status board indicates that CC's lab work results have been populated. The following labs are: HbG Hemoglobin: 9.1 g/dL (Female: 12 to 16 g/dL or 7.4 to 9.9 mmol/L (SI units) Hematocrit: 35% (Female: 37% to 47% or 0.37 to 0.47 volume fraction (SI units)) WBC: 11,150 mm3 (5000 to 10,000/mm³ or 5 to 10 × 10⁹/L (SI units) Fe: 65 mcg/dl (Female: 60 to 160 mcg/dL or 11 to 29 μmol/L (SI Units)) B12: 300 pg/mL (160-950 pg/mL or 118-701 pmol/L (SI units)) Folate: 4 ng/mL (Greater than 5.4 ng/mL or Greater than 12.2 nmol/L (SI units)) Na: 150 mEq/L (136 to 145 mEq/L or 136 to 145 mmol/L (SI units)) Potassium: 4.8 mEq/L (3.5 to 5.0 mEq/L or 3.5 to 5.0 mmol/L (SI units)) Your initial plan of care is:NEXT SCENARIO: Upon entering the room, you notice the patient is squatting in the corner. You also notice that the IV was removed, and the tubing is on the floor. Blood stains are apparent on her arm and gown. Affect is flat, and she gives limited eye contact. Patient appears to be chattering, but no one is present. You notice that her tray is full, but she only ate the packaged crackers. You relate the following dialogue to the translator:NEXT SCENARIO:You have determined that the patient is hallucinating, delusional, and is not oriented to time and place. She is disorganized in her speech and behavior; the patient is telling you that her Ancestors are warning her that we are trying to poison her. She only eats packaged food.NEXT SCENARIO:Patient resists allowing you to insert the IV. She threatens anyone who goes near her.NEXT SCENARIO:CC has had a psych evaluation, and there is an indication that she needs to be admitted to the psych floor. There are no open psych beds nor open beds in the ICU. You must manage the patient in her existing med-surg room.
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    Ann Rails38 years old, c/o back pain, non-significant past medical history. No known allergies (NKA). Vital signs -BP 124/82, Temp 98.2, P 84, RR 22, SaO2 96%. Pain and numbness in legs for one week. Abnormal left leg weakness, gait unsteady, 5/10 on numeric pain scale. Neuro WNL, except leg pain upon movement. Activity as tolerated with assistance. D/C plan- decrease pain and restore normal gait. Regular diet. Dr. SuculoSCENE 2: RN CONSIDERATIONSScene 3You enter patient's room. After washing and gloving hands, you then identify yourself and the patient, Ann Rails. You notice she is crying and is expressing fear that she "will always have this pain and numbness" and she doesn't think she can cope.Scene 4Ms. Rails was medicated with hydrocodone 5 mg PO two hours ago and is now complaining of pain (8/10 pain scale).Scene 5Ms. Rails shares with you her fear of being discharged home to an abusive husband.Scene 6Upon entering the room, you find Ms. Rails sleeping. She has received a dose of Hydrocodone for PRN pain 20 minutes agoScene 7Ms. Rails states that she has not had a bowel movement (BM) in the past two days.
Q.2.
Educational increasedfall risk increasedhealth change increasedpain level normalpsych needs increasedsensorium increasedSCENE 2: NURSING CONSIDERATIONSPhysiological:Acute Pain FALSEDeficient Fluid Volume FALSEElectrolyte Imbalance TRUEImbalanced Fluid Volume, Risk for TRUEImpaired Skin Integrity, Risk for FALSEIneffective Renal Perfusion, Risk for TRUESafety:Acute Confusion TRUEDisturbed Sensory Perception FALSEFall, Risk for TRUESleep Deprivation FALSELove and belonging:Anxiety FALSEFailure to Thrive TRUEScene 3Wash and glove handsFull assessmentMonitor and evaluate fluid intakeEducate patientDocument resultsScene 4Wash and glove handsFull assessmentApply fall risk braceletDocument resultsScene 5Offer assistanceRemain with patientTherapeutic CommunicationNotify lead nurseDocument resultsScene 6Visual assessCall rapid responseApply oxygenEstablish second IVRemain with patientScene 7Give verbal reportEscort patientNotify familyDocument results
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    Lithia Monson, 93 years old, c/o head injury, r/o subdural hematoma. Hx of dementia, from nursing home, fall one day ago. No known allergies (NKA). Vital signs -Temp 97.2, BP 96/74, P 82, RR 20, SaO2 97%. Neuro- confusion to time and place, but oriented to self, speech clear, poor historian, did not recognize son today which is new for her; Neuro assessment and vital signs q1 hr. Skin warm dry, bruises on forehead with small laceration. Increased fall risk. DSD (dry sterile dressing), forehead laceration clean and dry intact. 20ga. Hep-Lock in place left AC. GI WNL. Cardiovascular has pacer with rate of 82bpm on demand. Strict I&O, regular diet, intake 50%. Waist belt restraint PRN; family sitter at bedside, assist with bath. Dr. Altace
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    Tom Richardson, 46yr-old. Dx- urinary stones with 3 episodes/5yrs. Allergic to sulfa drugs. Vital signs -Temp 98.4,BP 175/105, P 112, RR 28, SaO2 94%; Neuro- WNL's. Skin warm and pale. Generalized weakness, blood tinged urine and severe pain upon urination, GI- n/v. Clear liquid diet. Strict I&O and strain all urine, filters in bathroom. Patient demonstrates urine strain procedure. Severe pain (10/10) medicated q 30 minutes x4 with IV Morphine 2mg with little relief. IV D5 1/2 NS @100ml/hr. Dr. Small at bedside with patient and family. Stat lithotripsy treatment ordered. Awaiting transport.SCENE 2; NURSING CONSIDERATIONSScene 3Day 2 admission, Thomas Richardson is complaining of severe pain and is now begging you for some relief; states pain scale 10/10.Scene 4Mr. Richardson is now vomiting and shows no relief 45 minutes after receiving pain medicationScene 5Mr. Richardson is requesting assistance to ambulate to bathroom.Scene 6Mr. Richardson is now pain free and questioning why he is plagued with recurring urinary stones.Scene 7You are now preparing for discharge, place steps in order:
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    Tim Jones, 82 -year old male patient of Dr. Diggs just arrived this morning from the local nursing home. He was confused upon arrival. During the initial assessment, fresh and various stages of bruise healing 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.SCENE 2 : RN CONSIDERATIONSScene 3You begin your shift assessment with Mr. Jones.Scene 4Mr. Jones is scheduled for a full body CT scan. Mr. Jones stated to the nurse that he "was scared to leave the room." Further questioning and clarification revealed Mr. Jones does not want to be alone and is afraid of being hurtScene 5Later in the evening Mr. Jones falls on his way to the bathroom.Scene 6 Mr. Jones is resting quietly in the bed, respirations 22, slightly labored, color pink. Eyes closed. Upon assessment, Mr. Jones was noted to have bilateral wheezing, RR 24, some use of accessory muscles with respirations, dullness to percussion in the left lower lung lobe, and an unproductive cough. Based on assessment, nebulizer treatment administered per MD orders.Scene 7Mr. Jones is now more alert and states he does not see the point in living anymore and wishes he would just die quietly. He asks to speak to a Clergy member. He does not want to return to the nursing home, and does not wish to burden or live with his children. He insists that he is not hungry and refuses assistance with his meal. He requests no visitors at this time, but later asks for his family to be called to discuss a plan of care.
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    Sarah Getts, 77 yr-old, Dx- Chronic Renal Failure, admitted with hyperkalemia (5.9, Eq/L)/hyponatremia (128mEq/L). No known allergies (NKA). Vital signs -Temp 98.8, BP 102/76, P 102- irregular, RR 22, SaO2 90%, cardiovascular on telemetry with Sinus irregular rhythm. Disoriented to time and place, speech slurred. Pupils PERRLA, eyes clear. 20 ga. Hep-Lock in right forearm, skin warm and dry, generalized weakness with recent weight loss. 50% intake. High fall risk. Renal diet. Family in room with patient very concerned. Dr. BrownSCENE 2 : NURSING CONSIDERATIONSScene 3Ms. Getts is requesting water to drink. Her pitcher has already been filled three times this shift.Scene 4Three hours later, Ms. Getts is unsteady when standing by her bedside.Scene 5You observe Ms. Getts being assisted by another nurse who is being blatantly rude and disrespectful to her.Scene 6Ms. Getts is now complaining of sudden sharp, substernal chest pain, very short of breath and is profusely diaphoretic.Scene 7Ms. Getts is being transferred as an emergency to Critical Care. Your responsibilities are:
Q.3.
Educational increasedfall risk increasedhealth change increasedpain level normalpsych needs normalsensorium normalSCENE 2 : RN CONSIDERATIONSPhysiological:Acute Pain TRUEElectrolyte Imbalance FALSEImbalanced Nutrition FALSEImpaired Mobility, Risk for TRUEImpaired Skin Integrity, Risk for FALSEImpaired Urinary Elimination TRUESafety:Fall, Risk for TRUE Sleep Deprivation FALSEScene 3Wash and glove handsVital assessmentAdminister pain medicationsRe-assess patientDocument resultsScene 4Vital assessmentNotify doctor for pain medicationsAdminister new pain medicationsRe-assess patientScene 5Use therapeutic communication/Active ListeningObtain urinary screenAssist patientRemain with patientDocument results and findingsScene 6Use therapeutic communication/Active ListeningEducate patientEvaluate understandingContact dietary consultDocument resultsScene 7Discharge instructionsEvaluate understandingEscort patient to vehicleDocument resultsNotify housekeeping
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    Tim Jones, 82 -year old male patient of Dr. Diggs just arrived this morning from the local nursing home. He was confused upon arrival. During the initial assessment, fresh and various stages of bruise healing 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.SCENE 2 : RN CONSIDERATIONSScene 3You begin your shift assessment with Mr. Jones.Scene 4Mr. Jones is scheduled for a full body CT scan. Mr. Jones stated to the nurse that he "was scared to leave the room." Further questioning and clarification revealed Mr. Jones does not want to be alone and is afraid of being hurtScene 5Later in the evening Mr. Jones falls on his way to the bathroom.Scene 6 Mr. Jones is resting quietly in the bed, respirations 22, slightly labored, color pink. Eyes closed. Upon assessment, Mr. Jones was noted to have bilateral wheezing, RR 24, some use of accessory muscles with respirations, dullness to percussion in the left lower lung lobe, and an unproductive cough. Based on assessment, nebulizer treatment administered per MD orders.Scene 7Mr. Jones is now more alert and states he does not see the point in living anymore and wishes he would just die quietly. He asks to speak to a Clergy member. He does not want to return to the nursing home, and does not wish to burden or live with his children. He insists that he is not hungry and refuses assistance with his meal. He requests no visitors at this time, but later asks for his family to be called to discuss a plan of care.
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    Tom Richardson, 46yr-old. Dx- urinary stones with 3 episodes/5yrs. Allergic to sulfa drugs. Vital signs -Temp 98.4,BP 175/105, P 112, RR 28, SaO2 94%; Neuro- WNL's. Skin warm and pale. Generalized weakness, blood tinged urine and severe pain upon urination, GI- n/v. Clear liquid diet. Strict I&O and strain all urine, filters in bathroom. Patient demonstrates urine strain procedure. Severe pain (10/10) medicated q 30 minutes x4 with IV Morphine 2mg with little relief. IV D5 1/2 NS @100ml/hr. Dr. Small at bedside with patient and family. Stat lithotripsy treatment ordered. Awaiting transport.SCENE 2; NURSING CONSIDERATIONSScene 3Day 2 admission, Thomas Richardson is complaining of severe pain and is now begging you for some relief; states pain scale 10/10.Scene 4Mr. Richardson is now vomiting and shows no relief 45 minutes after receiving pain medicationScene 5Mr. Richardson is requesting assistance to ambulate to bathroom.Scene 6Mr. Richardson is now pain free and questioning why he is plagued with recurring urinary stones.Scene 7You are now preparing for discharge, place steps in order:
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    Sarah Getts, 77 yr-old, Dx- Chronic Renal Failure, admitted with hyperkalemia (5.9, Eq/L)/hyponatremia (128mEq/L). No known allergies (NKA). Vital signs -Temp 98.8, BP 102/76, P 102- irregular, RR 22, SaO2 90%, cardiovascular on telemetry with Sinus irregular rhythm. Disoriented to time and place, speech slurred. Pupils PERRLA, eyes clear. 20 ga. Hep-Lock in right forearm, skin warm and dry, generalized weakness with recent weight loss. 50% intake. High fall risk. Renal diet. Family in room with patient very concerned. Dr. BrownSCENE 2 : NURSING CONSIDERATIONSScene 3Ms. Getts is requesting water to drink. Her pitcher has already been filled three times this shift.Scene 4Three hours later, Ms. Getts is unsteady when standing by her bedside.Scene 5You observe Ms. Getts being assisted by another nurse who is being blatantly rude and disrespectful to her.Scene 6Ms. Getts is now complaining of sudden sharp, substernal chest pain, very short of breath and is profusely diaphoretic.Scene 7Ms. Getts is being transferred as an emergency to Critical Care. Your responsibilities are:
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    Lithia Monson, 93 years old, c/o head injury, r/o subdural hematoma. Hx of dementia, from nursing home, fall one day ago. No known allergies (NKA). Vital signs -Temp 97.2, BP 96/74, P 82, RR 20, SaO2 97%. Neuro- confusion to time and place, but oriented to self, speech clear, poor historian, did not recognize son today which is new for her; Neuro assessment and vital signs q1 hr. Skin warm dry, bruises on forehead with small laceration. Increased fall risk. DSD (dry sterile dressing), forehead laceration clean and dry intact. 20ga. Hep-Lock in place left AC. GI WNL. Cardiovascular has pacer with rate of 82bpm on demand. Strict I&O, regular diet, intake 50%. Waist belt restraint PRN; family sitter at bedside, assist with bath. Dr. Altace
Q.4.
Educational increasedfall risk increasedhealth change increasedpain level normalpsych needs increasedsensorium increased
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    Tim Jones, 82 -year old male patient of Dr. Diggs just arrived this morning from the local nursing home. He was confused upon arrival. During the initial assessment, fresh and various stages of bruise healing 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.SCENE 2 : RN CONSIDERATIONSScene 3You begin your shift assessment with Mr. Jones.Scene 4Mr. Jones is scheduled for a full body CT scan. Mr. Jones stated to the nurse that he "was scared to leave the room." Further questioning and clarification revealed Mr. Jones does not want to be alone and is afraid of being hurtScene 5Later in the evening Mr. Jones falls on his way to the bathroom.Scene 6 Mr. Jones is resting quietly in the bed, respirations 22, slightly labored, color pink. Eyes closed. Upon assessment, Mr. Jones was noted to have bilateral wheezing, RR 24, some use of accessory muscles with respirations, dullness to percussion in the left lower lung lobe, and an unproductive cough. Based on assessment, nebulizer treatment administered per MD orders.Scene 7Mr. Jones is now more alert and states he does not see the point in living anymore and wishes he would just die quietly. He asks to speak to a Clergy member. He does not want to return to the nursing home, and does not wish to burden or live with his children. He insists that he is not hungry and refuses assistance with his meal. He requests no visitors at this time, but later asks for his family to be called to discuss a plan of care.
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    Tom Richardson, 46yr-old. Dx- urinary stones with 3 episodes/5yrs. Allergic to sulfa drugs. Vital signs -Temp 98.4,BP 175/105, P 112, RR 28, SaO2 94%; Neuro- WNL's. Skin warm and pale. Generalized weakness, blood tinged urine and severe pain upon urination, GI- n/v. Clear liquid diet. Strict I&O and strain all urine, filters in bathroom. Patient demonstrates urine strain procedure. Severe pain (10/10) medicated q 30 minutes x4 with IV Morphine 2mg with little relief. IV D5 1/2 NS @100ml/hr. Dr. Small at bedside with patient and family. Stat lithotripsy treatment ordered. Awaiting transport.SCENE 2; NURSING CONSIDERATIONSScene 3Day 2 admission, Thomas Richardson is complaining of severe pain and is now begging you for some relief; states pain scale 10/10.Scene 4Mr. Richardson is now vomiting and shows no relief 45 minutes after receiving pain medicationScene 5Mr. Richardson is requesting assistance to ambulate to bathroom.Scene 6Mr. Richardson is now pain free and questioning why he is plagued with recurring urinary stones.Scene 7You are now preparing for discharge, place steps in order:
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    Lithia Monson, 93 years old, c/o head injury, r/o subdural hematoma. Hx of dementia, from nursing home, fall one day ago. No known allergies (NKA). Vital signs -Temp 97.2, BP 96/74, P 82, RR 20, SaO2 97%. Neuro- confusion to time and place, but oriented to self, speech clear, poor historian, did not recognize son today which is new for her; Neuro assessment and vital signs q1 hr. Skin warm dry, bruises on forehead with small laceration. Increased fall risk. DSD (dry sterile dressing), forehead laceration clean and dry intact. 20ga. Hep-Lock in place left AC. GI WNL. Cardiovascular has pacer with rate of 82bpm on demand. Strict I&O, regular diet, intake 50%. Waist belt restraint PRN; family sitter at bedside, assist with bath. Dr. Altace
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    Sarah Getts, 77 yr-old, Dx- Chronic Renal Failure, admitted with hyperkalemia (5.9, Eq/L)/hyponatremia (128mEq/L). No known allergies (NKA). Vital signs -Temp 98.8, BP 102/76, P 102- irregular, RR 22, SaO2 90%, cardiovascular on telemetry with Sinus irregular rhythm. Disoriented to time and place, speech slurred. Pupils PERRLA, eyes clear. 20 ga. Hep-Lock in right forearm, skin warm and dry, generalized weakness with recent weight loss. 50% intake. High fall risk. Renal diet. Family in room with patient very concerned. Dr. BrownSCENE 2 : NURSING CONSIDERATIONSScene 3Ms. Getts is requesting water to drink. Her pitcher has already been filled three times this shift.Scene 4Three hours later, Ms. Getts is unsteady when standing by her bedside.Scene 5You observe Ms. Getts being assisted by another nurse who is being blatantly rude and disrespectful to her.Scene 6Ms. Getts is now complaining of sudden sharp, substernal chest pain, very short of breath and is profusely diaphoretic.Scene 7Ms. Getts is being transferred as an emergency to Critical Care. Your responsibilities are:
Q.5.
Educational need increasedfall risk increasedHealth change increasedneuro normalpain level normalpatient needs increasedScene 2: Nursing concerns:Physiological FALSEBleeding FalseDeath anxiety TRUEDisturbed Body Image FALSEEsteem FALSEImpaired Acute Confusion FALSEImpaired Gas Exchange TRUEIneffective breathing pattern TRUEKnowledge deficit TRUEPain, Acute FALSEPhysical Mobility, ImpairedSkin Integrity FALSEScene 3Don appropriate PPE.Change to simple O2 face mask per Healthcare providerPerform focused respiratory assessment.Notify respiratory therapist to begin treatment.Notify family to self-isolate for 14 daysScene 4Reorient patient to setting using therapeutic communication.Obtain a sitter/UAP.Restart the IV.Begin strict I&O.Obtain an order to insert a foley catheter.Scene 5Use therapeutic communication to explain necessary procedure.Position the patient properly.Create sterile field with foley kit on the bedside table and don sterile gloves.Instruct Lucy to assist in maintaining patient position and field sterilityInsert foley catheter according to hospital recommended guidelines,to ensure sterility of catheter.Scene 6Make sure O2 mask is secure and free of sputum.Ensure patient is in fowlers position.Check the foley catheter to make sure it is not obstructed.Notify Rapid Response team (RRT).Provide initial report and assist RRT.Scene 7Mr. Raymond, COVID-19 positive, in severe respiratory distress, rapid response called.Patient has a history of COPD, hypertension, diabetes type II, and a recent myocardial infarction. Patient received Furosemide Lasix 20mg, IVP x2, on Claforan Q4, and on sliding scale Insulin.Intubated by RRT, BP: 88/58, P: 110, T: 101.2, SaO2: 94%, ABG's are pending. Foley catheter in place.Recommend patient be transferred to ICU.Accompany your patient to ICU and give report to receiving nurse.
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    Tim Jones, 82 -year old male patient of Dr. Diggs just arrived this morning from the local nursing home. He was confused upon arrival. During the initial assessment, fresh and various stages of bruise healing 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.SCENE 2 : RN CONSIDERATIONSScene 3You begin your shift assessment with Mr. Jones.Scene 4Mr. Jones is scheduled for a full body CT scan. Mr. Jones stated to the nurse that he "was scared to leave the room." Further questioning and clarification revealed Mr. Jones does not want to be alone and is afraid of being hurtScene 5Later in the evening Mr. Jones falls on his way to the bathroom.Scene 6 Mr. Jones is resting quietly in the bed, respirations 22, slightly labored, color pink. Eyes closed. Upon assessment, Mr. Jones was noted to have bilateral wheezing, RR 24, some use of accessory muscles with respirations, dullness to percussion in the left lower lung lobe, and an unproductive cough. Based on assessment, nebulizer treatment administered per MD orders.Scene 7Mr. Jones is now more alert and states he does not see the point in living anymore and wishes he would just die quietly. He asks to speak to a Clergy member. He does not want to return to the nursing home, and does not wish to burden or live with his children. He insists that he is not hungry and refuses assistance with his meal. He requests no visitors at this time, but later asks for his family to be called to discuss a plan of care.
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    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. He has orders for dressing changes q daily, and pain medications prior to the dressing change.SCENE 2: RN CONSIDERATIONSScene 3Mr. Wright reports pain 6/10, and is requesting medication prior to dressing changeScene 4Mr. Wright insists that he watches TV from the High Fowler's position. The nurse repositioned the patient to the left side to decrease pressure on the sacrum and right heel. Sacrum pressure injury demonstrates underlying bone exposure wound measures 4 cm x 6 cm x 3 cm depth with tunneling noted on the right side. The right heel demonstrates a blister 2 cm x 1 cm with clear fluid noted.Scene 5The Healthcare Provider is requesting an update on sacral wound healing.Scene 6It is now time for Mr. Wright's sacral dressing change as the dressing seal is compromised and drainage is visible on the outer layer. See the plan of care: 1. Sterile Normal Saline wet-to-dry dressing changes daily. 2. Apply Triple antibiotic ointment to edges of wound each dressing change 3. Notify MD of worsening changes to wound based on measurements and appearance 4. Medicate with Demerol 100 mg with Phenergan 25 mg IM prior to dressing change 5. Change diet to Heart Healthy Diet 6. D/C Docusate Sodium if patient complains of diarrhea 7. Change IV fluids to 75 mL/hr 8. Encourage PO fluids 9. Nutrition consult.Scene 710 days later, Mr. Wright's wounds are healing, and you have orders to prepare for discharge with home healthcare. Mr. Wright states "There is no way I can walk up the stairs to get into my house with this big dressing on my foot."
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    CCChanthavy Chhet, 46 y/o female admitted for dehydration and gastritis. She is accompanied by her uncle who speaks fluent English, but patient speaks little to no English and is a Cambodian native. The uncle suggests that nursing staff address the patient by CC. Family is concerned that she has not been eating or drinking. Her non-verbal communication indicates abdominal discomfort. Vital signs are: T: 99.4 F, 37.4 C, P:92, R:18, PaO2: 98%, BP: 102/82 sitting, BP: 90/64 standingScene 2: Acuity 3select appropriate concerns based on info:Scene 3: CC's initial admitting orders include starting an IV D5 ½ NS at 100mL an hour, regular diet is tolerated. Status board indicates that CC's lab work results have been populated. The following labs are: HbG Hemoglobin: 9.1 g/dL (Female: 12 to 16 g/dL or 7.4 to 9.9 mmol/L (SI units) Hematocrit: 35% (Female: 37% to 47% or 0.37 to 0.47 volume fraction (SI units)) WBC: 11,150 mm3 (5000 to 10,000/mm³ or 5 to 10 × 10⁹/L (SI units) Fe: 65 mcg/dl (Female: 60 to 160 mcg/dL or 11 to 29 μmol/L (SI Units)) B12: 300 pg/mL (160-950 pg/mL or 118-701 pmol/L (SI units)) Folate: 4 ng/mL (Greater than 5.4 ng/mL or Greater than 12.2 nmol/L (SI units)) Na: 150 mEq/L (136 to 145 mEq/L or 136 to 145 mmol/L (SI units)) Potassium: 4.8 mEq/L (3.5 to 5.0 mEq/L or 3.5 to 5.0 mmol/L (SI units)) Your initial plan of care is:NEXT SCENARIO: Upon entering the room, you notice the patient is squatting in the corner. You also notice that the IV was removed, and the tubing is on the floor. Blood stains are apparent on her arm and gown. Affect is flat, and she gives limited eye contact. Patient appears to be chattering, but no one is present. You notice that her tray is full, but she only ate the packaged crackers. You relate the following dialogue to the translator:NEXT SCENARIO:You have determined that the patient is hallucinating, delusional, and is not oriented to time and place. She is disorganized in her speech and behavior; the patient is telling you that her Ancestors are warning her that we are trying to poison her. She only eats packaged food.NEXT SCENARIO:Patient resists allowing you to insert the IV. She threatens anyone who goes near her.NEXT SCENARIO:CC has had a psych evaluation, and there is an indication that she needs to be admitted to the psych floor. There are no open psych beds nor open beds in the ICU. You must manage the patient in her existing med-surg room.
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    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 q4hr 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.Scene 2: Select Nursing Concerns:Scene 3The next day, he tests positive for COVID 19 and his condition has deteriorated as he is now in respiratory distress. Mr. Raymond weighs 260 lbs. Vital Signs: BP is 92/58, Pulse 102, Respirations 30 and labored, Temperature 101.3, SaO2 91% . He has bilateral lower lobe atelectasis with bronchial/vesicular wheezing.Scene 4Mr. Raymond continues to deteriorate and becomes confused. In his confusion, he becomes combative and pulls out his IV. He is on a 100% nonrebreather and he keeps pulling his mask off. Just received an order to initiate 20 mg of Furosemide (Lasix) IVP, BID.Scene 5Order for a foley catheter has been obtained and Lucy Jones, LPN, is there to assist. Both nurses have donned appropriate PPE and have entered the room.Scene 6UAP reports urinary output of 50 mL over the past three hours. Repeat focused pulmonary assessment reveals profound bilateral atelectasis in the bases and frothy white sputum. Increased Respiratory rate of 32 and labored, peripheral edema +3 in both ankles and JVD. Based on findings, nursing care actions that are most concerning are:Scene 7:Mr. Raymond is stabilized with RRT. Give an SBAR to Hospitalist:
Q.6.
education increasedfall risk increasedhealth increasedneuro normalpain increasedpsych normalSCENE 2: RN CONSIDERATIONSPhysiologicalAcute Pain TRUEAltered Body Image TRUEConstipation FALSEImpaired Communication FALSEImpaired Physical Mobility TRUEImpaired Tissue Integrity TRUEIneffective Airway Clearance FALSEIneffective Breathing Pattern FALSERisk for Imbalanced Nutrition TRUESafety:Isolation Precaution FALSE Risk for Infection TRUERisk for Injury related to Falls TRUEScene 3Assess current pain level.Assess documented pain level and intervention by previous nurses.Review medication orders for pain.Prepare and administer appropriate pain medication.Reassess pain level.Scene 4Assess Mr. Wright's willingness to learn.Eliminate as many distractions as possible.Explain rationales for pressure relief to injured areas.Assess understanding through teach back.Document responses.Scene 5Remove old dressing with clean gloves daily.Assess the injury for presence of necrotic tissue and amount of exudate.Assess and document the condition of the skin surrounding the pressure injury in terms of color, temperature, texture, and moisture.Measure wound size at greatest length, width, and depth using a disposable paper tape measure.Re-apply new sterile dressing.Scene 6Don clean gloves and remove the old dressing.Remove clean gloves, wash hands, put on sterile gloves.Clean wound with sterile saline, apply triple antibiotic ointment per HCP order.Place sterile moistened sterile gauze in wound, place ABD pad over wound.Secure dressing in place with tape.Scene 7Explain signs and symptoms of wound infection.Encourage Mr. Wright to include high protein snacks in his diet.Assess understanding through teach back.Alert Mr. Wright's Case Manager of concerns of home environment.Call report to Home Care Nurse
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    Tim Jones, 82 -year old male patient of Dr. Diggs just arrived this morning from the local nursing home. He was confused upon arrival. During the initial assessment, fresh and various stages of bruise healing 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.SCENE 2 : RN CONSIDERATIONSScene 3You begin your shift assessment with Mr. Jones.Scene 4Mr. Jones is scheduled for a full body CT scan. Mr. Jones stated to the nurse that he "was scared to leave the room." Further questioning and clarification revealed Mr. Jones does not want to be alone and is afraid of being hurtScene 5Later in the evening Mr. Jones falls on his way to the bathroom.Scene 6 Mr. Jones is resting quietly in the bed, respirations 22, slightly labored, color pink. Eyes closed. Upon assessment, Mr. Jones was noted to have bilateral wheezing, RR 24, some use of accessory muscles with respirations, dullness to percussion in the left lower lung lobe, and an unproductive cough. Based on assessment, nebulizer treatment administered per MD orders.Scene 7Mr. Jones is now more alert and states he does not see the point in living anymore and wishes he would just die quietly. He asks to speak to a Clergy member. He does not want to return to the nursing home, and does not wish to burden or live with his children. He insists that he is not hungry and refuses assistance with his meal. He requests no visitors at this time, but later asks for his family to be called to discuss a plan of care.
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    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. He has orders for dressing changes q daily, and pain medications prior to the dressing change.SCENE 2: RN CONSIDERATIONSScene 3Mr. Wright reports pain 6/10, and is requesting medication prior to dressing changeScene 4Mr. Wright insists that he watches TV from the High Fowler's position. The nurse repositioned the patient to the left side to decrease pressure on the sacrum and right heel. Sacrum pressure injury demonstrates underlying bone exposure wound measures 4 cm x 6 cm x 3 cm depth with tunneling noted on the right side. The right heel demonstrates a blister 2 cm x 1 cm with clear fluid noted.Scene 5The Healthcare Provider is requesting an update on sacral wound healing.Scene 6It is now time for Mr. Wright's sacral dressing change as the dressing seal is compromised and drainage is visible on the outer layer. See the plan of care: 1. Sterile Normal Saline wet-to-dry dressing changes daily. 2. Apply Triple antibiotic ointment to edges of wound each dressing change 3. Notify MD of worsening changes to wound based on measurements and appearance 4. Medicate with Demerol 100 mg with Phenergan 25 mg IM prior to dressing change 5. Change diet to Heart Healthy Diet 6. D/C Docusate Sodium if patient complains of diarrhea 7. Change IV fluids to 75 mL/hr 8. Encourage PO fluids 9. Nutrition consult.Scene 710 days later, Mr. Wright's wounds are healing, and you have orders to prepare for discharge with home healthcare. Mr. Wright states "There is no way I can walk up the stairs to get into my house with this big dressing on my foot."
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    Mary Barkley, 74y/o female has been admitted to your floor with a respiratory infection and she has tested positive for COVID19. She resides in an assisted living facility which has seen four deaths related to COVID19. 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 99.8 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.Scene 2, Nursing ConcernsScene 3Have patient verbalize understanding of treatment and future needsScene 4Mrs. Barkley is becoming more adamant about leaving while her physical condition continues to deteriorate. Her Temp is 100.8 BP 100/62 P 92 R 21 SpaO2 91. The nurse auscultates fine crackles in her lungs bilaterally, but her sputum is clear. She is oriented x3 but at times seems to be talking to someone in the room when no one is present. She told the nurse that she does not want a breathing tube, but her family has told the nurse by phone that they want every effort done to save her. She pulled out her IV and it will need to be restarted for her IV cipro dose that is due now. The nurse has another high acuity admission that has just arrived from the ER.Scene 5Ms. Barkley continues to deteriorate and is shouting for her family. She is disoriented and believes the nursing staff is trying to kill her. Her Temp is 101.3, BP 98/58, P 98, R 22, and PaO2 86%. The PCT is requesting to be relieved as the patient keeps pulling at the PCT's mask to see who she is. The nurse calls the attending provider requesting that Ms. Barkley be transferred to the ICU, but there are no rooms available. Instead the nurse is told to put the patient on telemetry and call RT for a CPAP trial.Scene 6The patient continues to be combative while attempting to initiate the CPAP trial. Healthcare provider has ordered Haldol in order to sedate the patient. Vital signs are deteriorating, BP 90/58, P 116, R 28, PaO2 85%, T 102.0 Enter the room after taking vital signs.Scene 7Ms. Barkley requires emergency intubation, and the Healthcare Provider on scene suggests that the patient did not want to be intubated. You, the nurse, are concerned because the family asked for everything to be done and the patient never signed a do not resuscitate order (DNR). The patient has now been sedated, and RT is temporarily maintaining their saturations with effective valve mask ventilation.
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    Ruth Cummings, Ruth Cummings, 68 y/o female admitted for acute LUQ abdominal pain with vomiting and nausea. Her pain is 9/10, greater after she eats. She has an allergy to soybean, and a history of breast cancer with a sinus tumor removal, hysterectomy, lumpectomy, and a thyroidectomy. She had an MRCP, also known as MRI Cholangiopancreatography, which showed a fatty liver and gallstones (cholelithiasis.) Patient expresses concern about what surgery could find because of her history with Cancer.SCENE 2 : NURSING CONSIDERATIONSScene 3Patient is admitted to the Medical Surgical unit and appears weak. She complains of pain, and the patency of her right wrist IV is questionable. Patient is NPO due to nausea and vomiting and is scheduled for a lap chole in the morning. You have orders to insert an NG tube to continuous low gomco suction and are awaiting further admission ordersScene 4Begin pre-op teaching on incentive spirometry (IS) in preparation for her lap chole surgeryScene 5OR transport arrives to take the patient to surgery. What needs to be done?Scene 6Patient has returned from lap chole with 5 puncture wounds with Band-Aids over each. Abdomen is distended, NG is out. Patient's IV remains in the same location. Patient is responding to verbal stimuli, and all 4 bed rails are up.Scene 7You enter the room to check on the patient, upon responding to the bathroom call bell. Upon entry into the bathroom, you find the patient supporting herself on vanity. Patient's IV is leaning over into the shower. Patient states, "I had to use the bathroom. When standing my knees buckled, I grabbed the IV pole, and the pole tipped over." Noted liquid on the floor, patient denies falling at this time, no abrasions noted, and patient denies injury. After speaking with the charge nurse, patient states, "My knees buckled, and I hit my elbows." When asked if anything else was hit, patient stated, "I landed on my bottom." After charge nurse left the room, patient reported, "I had fallen on my bottom after my knees buckled, then pulled myself up, and was supporting myself on the vanity when you walked in."
Q.7.
educational needs Increasedfall risk increasedhealth change increasedneuro normalpain level increasedScene 2Physiological:Acute pain TRUE Bleeding risk for False Impaired mobility, risk for TrueNausea True Safety:Cultural Competence True Deficient knowledge TrueGrieving FalseImpaired Verbal Communication TruePeripheral Neurovascular dysfunction FalseSCENE 3: PLACE IN ORDERObtain translatorInitiate IVBegin fluid and electrolyte replacementAdminister IV antibiotics, as orderedConsult with MD about initiating telemetryPLACE IN ORDER:What is going on?We need to stop the bleeding at the IV site with a bandage.Tell me where you are.Who were you talking to in the corner?What were the voices telling you?PLACE IN ORDER:Attempt to establish rapportNotify HCP of your findings, and suggest the need for a stat Psychiatric consultAttempt to re-start the IVContact dietary to send all food pre-packaged, paper disposable dishes, and no sharpsObtain a sitter, or family member to remain at bedside at all timesRemove potential harmful objects from the roomPLACE IN ORDER:Delay insertion of the IVContact HCP and explain patient's response to inserting the IV; request that HCP give a PRN order to manage psychosisContact CC's uncle to inform him of a change in statusRequest that the uncle come in to help manage the patientRequest that the uncle participates in the scheduled psych evaluationPLACE IN ORDER:Provide one-to-one observationInitiate anti-psychotic medication, as orderedEnsure family member is presentReassess environmentInitiate continuous observation and document every 15 minutes
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    Tim Jones, 82 -year old male patient of Dr. Diggs just arrived this morning from the local nursing home. He was confused upon arrival. During the initial assessment, fresh and various stages of bruise healing 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.SCENE 2 : RN CONSIDERATIONSScene 3You begin your shift assessment with Mr. Jones.Scene 4Mr. Jones is scheduled for a full body CT scan. Mr. Jones stated to the nurse that he "was scared to leave the room." Further questioning and clarification revealed Mr. Jones does not want to be alone and is afraid of being hurtScene 5Later in the evening Mr. Jones falls on his way to the bathroom.Scene 6 Mr. Jones is resting quietly in the bed, respirations 22, slightly labored, color pink. Eyes closed. Upon assessment, Mr. Jones was noted to have bilateral wheezing, RR 24, some use of accessory muscles with respirations, dullness to percussion in the left lower lung lobe, and an unproductive cough. Based on assessment, nebulizer treatment administered per MD orders.Scene 7Mr. Jones is now more alert and states he does not see the point in living anymore and wishes he would just die quietly. He asks to speak to a Clergy member. He does not want to return to the nursing home, and does not wish to burden or live with his children. He insists that he is not hungry and refuses assistance with his meal. He requests no visitors at this time, but later asks for his family to be called to discuss a plan of care.
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    CCChanthavy Chhet, 46 y/o female admitted for dehydration and gastritis. She is accompanied by her uncle who speaks fluent English, but patient speaks little to no English and is a Cambodian native. The uncle suggests that nursing staff address the patient by CC. Family is concerned that she has not been eating or drinking. Her non-verbal communication indicates abdominal discomfort. Vital signs are: T: 99.4 F, 37.4 C, P:92, R:18, PaO2: 98%, BP: 102/82 sitting, BP: 90/64 standingScene 2: Acuity 3select appropriate concerns based on info:Scene 3: CC's initial admitting orders include starting an IV D5 ½ NS at 100mL an hour, regular diet is tolerated. Status board indicates that CC's lab work results have been populated. The following labs are: HbG Hemoglobin: 9.1 g/dL (Female: 12 to 16 g/dL or 7.4 to 9.9 mmol/L (SI units) Hematocrit: 35% (Female: 37% to 47% or 0.37 to 0.47 volume fraction (SI units)) WBC: 11,150 mm3 (5000 to 10,000/mm³ or 5 to 10 × 10⁹/L (SI units) Fe: 65 mcg/dl (Female: 60 to 160 mcg/dL or 11 to 29 μmol/L (SI Units)) B12: 300 pg/mL (160-950 pg/mL or 118-701 pmol/L (SI units)) Folate: 4 ng/mL (Greater than 5.4 ng/mL or Greater than 12.2 nmol/L (SI units)) Na: 150 mEq/L (136 to 145 mEq/L or 136 to 145 mmol/L (SI units)) Potassium: 4.8 mEq/L (3.5 to 5.0 mEq/L or 3.5 to 5.0 mmol/L (SI units)) Your initial plan of care is:NEXT SCENARIO: Upon entering the room, you notice the patient is squatting in the corner. You also notice that the IV was removed, and the tubing is on the floor. Blood stains are apparent on her arm and gown. Affect is flat, and she gives limited eye contact. Patient appears to be chattering, but no one is present. You notice that her tray is full, but she only ate the packaged crackers. You relate the following dialogue to the translator:NEXT SCENARIO:You have determined that the patient is hallucinating, delusional, and is not oriented to time and place. She is disorganized in her speech and behavior; the patient is telling you that her Ancestors are warning her that we are trying to poison her. She only eats packaged food.NEXT SCENARIO:Patient resists allowing you to insert the IV. She threatens anyone who goes near her.NEXT SCENARIO:CC has had a psych evaluation, and there is an indication that she needs to be admitted to the psych floor. There are no open psych beds nor open beds in the ICU. You must manage the patient in her existing med-surg room.
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    John Davis, is a 54 y/o male admitted for surgical resection and biopsy of multiple lesions on his back and shoulders. The patient is fair skinned with multiple moles on his shoulders and anterior and posterior torso. The patient is high risk for basal cell carcinoma and has had mole - mapping. Mr. Davis is very thin and reports an 8 lbs. weight loss over the last four months. He owns a land scape business, works outside, he also enjoys being out on his boat. He had a basil cell carcinoma removed from his forehead four years ago (Mohs micrographic surgery) which has left a large scar. Mr. Davis is concerned about potential scars from these lesions. He denies any other health issues. The patient does not smoke, but drinks 2 beers after work daily and more on the weekends. VS BP 150/89, P 62, R 14, T 98.2.Scene 2 Select ConcernsScene 3 The surgery went well, he had one partial thickness lesion on his shoulder and one of the lesions on his back are full thickness that will require staged closure or a possible skin graft. He has a 4x4 dressing on his right shoulder, two large dressings, and two smaller dressings on his back. His vital signs are stable. He has an IV NS to his left hand @ TKO. He received 2 liters intraoperatively. He was given Fentanyl 100 mg and Zofran 4mg in the PACU. The patient asks if he can go to the bathroom because he needs to void immediately.Scene 4The patient has been made aware that he has advanced basal cell carcinoma and has a poor prognosis. The largest dressing is saturated with serous sanguineous fluid. The patient is complaining of 8/10 pain from two of the partial thickness incisions on his back (he will need skin graft soon). Patient states the larger dressings on his back that are full thickness do not hurt at all. The patient has an order for dressing changes PRN. The patient is awaiting orders for chemotherapy. VS BP 162/90, P 99, R 20, T 98.9.Scene 5The nurse's aide reports that the Mr. J did not eat any of his lunch or dinner. The surgeon and oncologist had visited with the patient that morning. When ask the patient about his appetite the patient states that he is nauseated. The SL is occluded. The orders came to initiate Chemotherapy: vismodegib (Erivedge) is 150mg orally daily. The sonidegib (Odomzo) dose is 200 mg orally daily taken on an empty stomach, at least 1 hour before or 2 hours after a meal.Scene 6The nurse is still concerned about the patient's appetite the next day, 3 days post-op. The patient will be seeing an oncologist before his discharge and the surgeon has stated that he will need to have several more lesions removed ASAP. The patient has learned that his cancer is stage 4 basal cell and has metastasized. He has not been ambulating and has been laying on his back most of the time. When changing the dressings, the nurse notices that the one of wounds on his back appears inflamed and reddened as well. VS BP 150/80, P 82, R 14, T 100.8Scene 7The doctor has chosen to pursue a more aggressive chemotherapy agent related to metastasizing cancer and side effects (muscle cramps and gastrointestinal discomfort). The patient will continue chemotherapy after discharge and is being counseled for the placement of a peripherally inserted central catheter (PICC) and why he needs it. The patient will be receiving his chemotherapy from an outpatient infusion clinic. The patient is still not eating and seems complacent in his care. When inquiring about his support system the patient states that running a business does not allow much time for friends or family.
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    Mary Barkley, 74y/o female has been admitted to your floor with a respiratory infection and she has tested positive for COVID19. She resides in an assisted living facility which has seen four deaths related to COVID19. 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 99.8 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.Scene 2, Nursing ConcernsScene 3Have patient verbalize understanding of treatment and future needsScene 4Mrs. Barkley is becoming more adamant about leaving while her physical condition continues to deteriorate. Her Temp is 100.8 BP 100/62 P 92 R 21 SpaO2 91. The nurse auscultates fine crackles in her lungs bilaterally, but her sputum is clear. She is oriented x3 but at times seems to be talking to someone in the room when no one is present. She told the nurse that she does not want a breathing tube, but her family has told the nurse by phone that they want every effort done to save her. She pulled out her IV and it will need to be restarted for her IV cipro dose that is due now. The nurse has another high acuity admission that has just arrived from the ER.Scene 5Ms. Barkley continues to deteriorate and is shouting for her family. She is disoriented and believes the nursing staff is trying to kill her. Her Temp is 101.3, BP 98/58, P 98, R 22, and PaO2 86%. The PCT is requesting to be relieved as the patient keeps pulling at the PCT's mask to see who she is. The nurse calls the attending provider requesting that Ms. Barkley be transferred to the ICU, but there are no rooms available. Instead the nurse is told to put the patient on telemetry and call RT for a CPAP trial.Scene 6The patient continues to be combative while attempting to initiate the CPAP trial. Healthcare provider has ordered Haldol in order to sedate the patient. Vital signs are deteriorating, BP 90/58, P 116, R 28, PaO2 85%, T 102.0 Enter the room after taking vital signs.Scene 7Ms. Barkley requires emergency intubation, and the Healthcare Provider on scene suggests that the patient did not want to be intubated. You, the nurse, are concerned because the family asked for everything to be done and the patient never signed a do not resuscitate order (DNR). The patient has now been sedated, and RT is temporarily maintaining their saturations with effective valve mask ventilation.
Q.8.
education increasedfall risk normalhealth increasedneuro normalpain increasedpsych increasedScene 2: Nursing ConcernsAcute Pain TRUEDeficient Knowledge TRUEGrieving TRUEImpaired Comfort TRUEInfection TRUEScene 3Have patient put on a maskWash hands and don PPEUse therapeutic communication to comfort patientGuide her back to her room while teaching her that her isolation is to protect others including her family.Set her up with a video chat with her family.Scene 4Initiate O2 at 2L nasal-cannula.Alert the charge nurse that Ms. Barkley is deteriorating and you need to remain with her. Ask the charge nurse to assign another nurse to the new admission.Have an aide sit with Ms. Barkley while you obtain the IV supplies, and notify the Healthcare Provider of her declining condition.Wash hands and dawn PPE and restart IV and secure with gauze wrap.Secure sitter to stay with Ms. Barkley after the insertion of the new IV.Scene 5Contact RT for a stat CPAP trial.Obtain telemetry set-up and take to patients roomAsk PCT to secure mask better, and inform her that there is no replacement for her.Don PPE and have PCT assist with connecting the patient to Telemetry.Assist RT to initiate CPAP trial.Scene 6Call rapid response, RRT.Continue to assist RT in ventilation.Give SBAR to RRT upon arrival.Call for crash-cart for possible intubation.Ensure documentation of time and events of RRT.Scene 7Encourage Healthcare Provider to consider intubation in the absence of signed DNR.Offer to contact family for Healthcare Provider.Contact Assisted Living facility (ALF) to see if patient has an Advanced Directive in place declining.Notify the Healthcare Provider of absence of Advanced Directive and families request to intubate.Assist with intubation, and logistics of managing the critical patient on the floor.
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    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. He has orders for dressing changes q daily, and pain medications prior to the dressing change.SCENE 2: RN CONSIDERATIONSScene 3Mr. Wright reports pain 6/10, and is requesting medication prior to dressing changeScene 4Mr. Wright insists that he watches TV from the High Fowler's position. The nurse repositioned the patient to the left side to decrease pressure on the sacrum and right heel. Sacrum pressure injury demonstrates underlying bone exposure wound measures 4 cm x 6 cm x 3 cm depth with tunneling noted on the right side. The right heel demonstrates a blister 2 cm x 1 cm with clear fluid noted.Scene 5The Healthcare Provider is requesting an update on sacral wound healing.Scene 6It is now time for Mr. Wright's sacral dressing change as the dressing seal is compromised and drainage is visible on the outer layer. See the plan of care: 1. Sterile Normal Saline wet-to-dry dressing changes daily. 2. Apply Triple antibiotic ointment to edges of wound each dressing change 3. Notify MD of worsening changes to wound based on measurements and appearance 4. Medicate with Demerol 100 mg with Phenergan 25 mg IM prior to dressing change 5. Change diet to Heart Healthy Diet 6. D/C Docusate Sodium if patient complains of diarrhea 7. Change IV fluids to 75 mL/hr 8. Encourage PO fluids 9. Nutrition consult.Scene 710 days later, Mr. Wright's wounds are healing, and you have orders to prepare for discharge with home healthcare. Mr. Wright states "There is no way I can walk up the stairs to get into my house with this big dressing on my foot."
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    Mary Barkley, 74y/o female has been admitted to your floor with a respiratory infection and she has tested positive for COVID19. She resides in an assisted living facility which has seen four deaths related to COVID19. 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 99.8 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.Scene 2, Nursing ConcernsScene 3Have patient verbalize understanding of treatment and future needsScene 4Mrs. Barkley is becoming more adamant about leaving while her physical condition continues to deteriorate. Her Temp is 100.8 BP 100/62 P 92 R 21 SpaO2 91. The nurse auscultates fine crackles in her lungs bilaterally, but her sputum is clear. She is oriented x3 but at times seems to be talking to someone in the room when no one is present. She told the nurse that she does not want a breathing tube, but her family has told the nurse by phone that they want every effort done to save her. She pulled out her IV and it will need to be restarted for her IV cipro dose that is due now. The nurse has another high acuity admission that has just arrived from the ER.Scene 5Ms. Barkley continues to deteriorate and is shouting for her family. She is disoriented and believes the nursing staff is trying to kill her. Her Temp is 101.3, BP 98/58, P 98, R 22, and PaO2 86%. The PCT is requesting to be relieved as the patient keeps pulling at the PCT's mask to see who she is. The nurse calls the attending provider requesting that Ms. Barkley be transferred to the ICU, but there are no rooms available. Instead the nurse is told to put the patient on telemetry and call RT for a CPAP trial.Scene 6The patient continues to be combative while attempting to initiate the CPAP trial. Healthcare provider has ordered Haldol in order to sedate the patient. Vital signs are deteriorating, BP 90/58, P 116, R 28, PaO2 85%, T 102.0 Enter the room after taking vital signs.Scene 7Ms. Barkley requires emergency intubation, and the Healthcare Provider on scene suggests that the patient did not want to be intubated. You, the nurse, are concerned because the family asked for everything to be done and the patient never signed a do not resuscitate order (DNR). The patient has now been sedated, and RT is temporarily maintaining their saturations with effective valve mask ventilation.
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    John Davis, is a 54 y/o male admitted for surgical resection and biopsy of multiple lesions on his back and shoulders. The patient is fair skinned with multiple moles on his shoulders and anterior and posterior torso. The patient is high risk for basal cell carcinoma and has had mole - mapping. Mr. Davis is very thin and reports an 8 lbs. weight loss over the last four months. He owns a land scape business, works outside, he also enjoys being out on his boat. He had a basil cell carcinoma removed from his forehead four years ago (Mohs micrographic surgery) which has left a large scar. Mr. Davis is concerned about potential scars from these lesions. He denies any other health issues. The patient does not smoke, but drinks 2 beers after work daily and more on the weekends. VS BP 150/89, P 62, R 14, T 98.2.Scene 2 Select ConcernsScene 3 The surgery went well, he had one partial thickness lesion on his shoulder and one of the lesions on his back are full thickness that will require staged closure or a possible skin graft. He has a 4x4 dressing on his right shoulder, two large dressings, and two smaller dressings on his back. His vital signs are stable. He has an IV NS to his left hand @ TKO. He received 2 liters intraoperatively. He was given Fentanyl 100 mg and Zofran 4mg in the PACU. The patient asks if he can go to the bathroom because he needs to void immediately.Scene 4The patient has been made aware that he has advanced basal cell carcinoma and has a poor prognosis. The largest dressing is saturated with serous sanguineous fluid. The patient is complaining of 8/10 pain from two of the partial thickness incisions on his back (he will need skin graft soon). Patient states the larger dressings on his back that are full thickness do not hurt at all. The patient has an order for dressing changes PRN. The patient is awaiting orders for chemotherapy. VS BP 162/90, P 99, R 20, T 98.9.Scene 5The nurse's aide reports that the Mr. J did not eat any of his lunch or dinner. The surgeon and oncologist had visited with the patient that morning. When ask the patient about his appetite the patient states that he is nauseated. The SL is occluded. The orders came to initiate Chemotherapy: vismodegib (Erivedge) is 150mg orally daily. The sonidegib (Odomzo) dose is 200 mg orally daily taken on an empty stomach, at least 1 hour before or 2 hours after a meal.Scene 6The nurse is still concerned about the patient's appetite the next day, 3 days post-op. The patient will be seeing an oncologist before his discharge and the surgeon has stated that he will need to have several more lesions removed ASAP. The patient has learned that his cancer is stage 4 basal cell and has metastasized. He has not been ambulating and has been laying on his back most of the time. When changing the dressings, the nurse notices that the one of wounds on his back appears inflamed and reddened as well. VS BP 150/80, P 82, R 14, T 100.8Scene 7The doctor has chosen to pursue a more aggressive chemotherapy agent related to metastasizing cancer and side effects (muscle cramps and gastrointestinal discomfort). The patient will continue chemotherapy after discharge and is being counseled for the placement of a peripherally inserted central catheter (PICC) and why he needs it. The patient will be receiving his chemotherapy from an outpatient infusion clinic. The patient is still not eating and seems complacent in his care. When inquiring about his support system the patient states that running a business does not allow much time for friends or family.
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    Ruth Cummings, Ruth Cummings, 68 y/o female admitted for acute LUQ abdominal pain with vomiting and nausea. Her pain is 9/10, greater after she eats. She has an allergy to soybean, and a history of breast cancer with a sinus tumor removal, hysterectomy, lumpectomy, and a thyroidectomy. She had an MRCP, also known as MRI Cholangiopancreatography, which showed a fatty liver and gallstones (cholelithiasis.) Patient expresses concern about what surgery could find because of her history with Cancer.SCENE 2 : NURSING CONSIDERATIONSScene 3Patient is admitted to the Medical Surgical unit and appears weak. She complains of pain, and the patency of her right wrist IV is questionable. Patient is NPO due to nausea and vomiting and is scheduled for a lap chole in the morning. You have orders to insert an NG tube to continuous low gomco suction and are awaiting further admission ordersScene 4Begin pre-op teaching on incentive spirometry (IS) in preparation for her lap chole surgeryScene 5OR transport arrives to take the patient to surgery. What needs to be done?Scene 6Patient has returned from lap chole with 5 puncture wounds with Band-Aids over each. Abdomen is distended, NG is out. Patient's IV remains in the same location. Patient is responding to verbal stimuli, and all 4 bed rails are up.Scene 7You enter the room to check on the patient, upon responding to the bathroom call bell. Upon entry into the bathroom, you find the patient supporting herself on vanity. Patient's IV is leaning over into the shower. Patient states, "I had to use the bathroom. When standing my knees buckled, I grabbed the IV pole, and the pole tipped over." Noted liquid on the floor, patient denies falling at this time, no abrasions noted, and patient denies injury. After speaking with the charge nurse, patient states, "My knees buckled, and I hit my elbows." When asked if anything else was hit, patient stated, "I landed on my bottom." After charge nurse left the room, patient reported, "I had fallen on my bottom after my knees buckled, then pulled myself up, and was supporting myself on the vanity when you walked in."