- Impaired tissue integrity Infection, Risk for: False Perform focused respiratory assessment Full assessment Scenario #3 Scenario 1 Ineffective coping Functional ability Reassess pt's VS Educate pt Scenario 3 Scenario #3 Ask the pt. Assist w/ airway mgmt Explain to Mr. and Mrs. Notify doctor A group of university students conduct a survey regarding menstrual pain for their biology subject. Mr. Richardson is now pain free and questioning why he is plagued w/ recurring urinary stones. Administer ABX Explain procedure Request CNA to remain w/ pt Health Change - Increased This information Educate pt. Deficient knowledge: True Fall, risk for Mrs. Stukes is a failed laparoscopic cholecystectomy that resulted in a bowel resection with a temporary ileostomy in place. Apply O2 Scenario #5 Provide operative summary -Because of the patient's long bone fracture, you are aware that a Pulmonary embolus (PE) is a possibility Allow husband - Safety - increased, - Pain, acute She receives the pre-op medication. His . Document Document consults, Educational - increased Take VS not Assure pt. Pain - normal Encourage incentive spirometer Safety- Encourage use of IS Scenario 3 Notify charge nurse Assess documented pain Mary Barkley Check PRN on continuous pulse ox Document Use therapeutic communication/active listening Scenario 4 and legs. -Assure patient that she is safe in the hospital, and you will not leave her Use therapeutic Scenario 1 -Review of body systems and evaluate pain on a scale of 1-10 Update pt on d/c changes Administer the medication Draw digoxin/ CMP labs as ordered Full assessment Pain - normal Wash and glove hands Ask Mrs. Workman for 24-hour diet Hopelessness: False. Impaired gas exchange, risk for Doctor orders 1.) 3 Multiple bruises to the back Psychological Needs - normal Fall, risk for The pt states, "I am sick to my stomach and feel like I have bugs crawling all over me!!!" Scenario #5 - Disturbed body image, Scenario #1 VS & head-to-toe Infection Scenario #2 Scenario 5 Scenario #3 Provide supplies and needed instructions Wash hands & assess Use therapeutic communication/active listening Have daughter stay, Educational - increased Educational Needs: Increased acuity Practice using IS call report to home care RN, Educational Needs: Increased acuity Contact power of attorney IV with NS @ 125 mL/ hr. Nausea: False Evaluate understanding Swift River Joyce Workman Room 304. Seek clarification Ensure foley is draining PT to educate pt Ensure pt is in Fowler's position Pt. Deficient knowledge Complete pre-op -Inform Mr. Goodman that you are not allowed to print records, -Comfort New-patients-swift-river-med-surg-covid-new-patients-charlie-raymond Sensorium: Normal acuity, Physiological- Perform pre-op Sit at an eye level 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. Be honest with Cameron Just received an order to initiate 20mg of Furosemide (Lasix) IVP, BID. Psychological Needs: Increased acuity, Physiological - Listen to patient concerns 5-Call the night shift nurse that just left to ask if they had emptied the indwelling urinary catheter bag prior to report Encourage -If concerned about the accuracy, take BP with a manual cuff Disturbed body image: True 50 terms. Restart new IV Neurological: Increased acuity Scenario 5 Administer Epoetin Contact HCP Anxiety: True Perform initial assessment Instruct pt to lie supine for 6 hours Call for crash cart Obtain informed consent Obtain translator Contact Assisted Living Facility to see if pt has an advanced directive in place declining intubation. Psychological Needs - normal about Involve family, Educational- increased Ask the charge nurses to assign another nurse to the new admission. Put on gown Document Increase supplemental O2 Administer oxygen Pain - increased Take VS Take vitals - Infection, risk for, Scenario #1 Take VS Contact chaplain Explain reason Reassure pt. Notify doctor - Impaired comfort Remove NG Notify lead nurse Assess pain Virginia Smith Scenario 4 Scenario #2 Reassess VS IVF 0.9% NS peripheral line @ 100mL/hr 2.) This survey aimed to determine the frequency and symptoms of dysmenorrhea, as identified by differen. Document and prepare to txf to surgical ICU Multiple burn injuries have overwhelmed the local hospitals. Sensorium: Normal acuity, Educational Needs: Increased acuity Love and Belonging- Infection, Risk for: True. Acute Pain: True Educate pt regarding RRT's purpose, Physiological Impaired comfort Check cranial nerves Notify PT Bleeding, risk for: False Full assessment Sarah Getts Other labs were WNL. Pt. Assist with applying Remind CODE team to stop CPR and check for pulse Q5 minutes Scenario 1 Contact social services 5-100% O2 has not been effective in maintaining her PaO2. call light Pt received furosemide Lasix 20mg, IVP x2, on Claforan Q4, and on sliding scale insulin. Wash hands Impaired mobility - Fall Risk - increased Disturbed body, Scenario #1 Reassess VS Scenario 2 Discuss w/ pt. Fall, Risk for: True Educate pt. Notify Dr. Assist pt. Compromised Family Coping: False Psychological: Normal acuity Joyce Workman, Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Scenario #4 . Alteration of protective mechanisms: True. -Determine if drainage is increasing if she Administer new Remove infiltrated IV Instruct pt. Maintain strict I&O's Notify doctor (for possible removal) Offer resource Anxiety: False Verified answer. Contact Social Services for a new consult Deficient Fluid Volume: True Prepare and administer appropriate pain medication Impaired mobility: False Treat pt. Psychological Needs - increased 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. Swift River Linda Pittmon scenario. Encourage fluids/fiber/ambulation Educate pt -Tell the patient that the Chaplain from his church was looking for him, and is at the visitor desk Encourage pt. Pain - normal Explain to surgeon Scenario 2 Scenario 3 Fear/Anxiety: True. Notify MD Sacrum pressure injury demonstrates underlying bone exposure wound measures 4cm x 6cm x 3cm depth w/ tunneling noted on the rt side. Anxiety: True Do not probe further Health Change: Increased acuity Don 2nd set Wash hands Allow husband to make a quick one-minute visit - Pain - normal privacy Anxiety Put side rails up Address concerns Fall Risk - increased Have nursing personnel in the room when family visit, Gas exchange Clean wound Reassess pt. Note time when Peripheral neurovascular dysfunction: True. Risk for injury: True, Scenario 1 Assist the pt back to bed Instruct pt not to get out of bed w/o assistance -Sensory Assis pt. Assess for pain Health Change: Increased acuity Fall Risk: Normal acuity Seek clarification I HAVE INCLUDED ALL THE INFO! Document teaching Reasses temp in 1 hour Ensure IV access Verify call light/bed safety precautions Administer pain meds She is very excited about the surgery but is also apprehensive. Ensure documentation Insert new IV Sensorium - normal, Acute pain PT has been getting the patient up with a walker and she is able to take a few steps. You determine to apply the restraint now. Construct dietary consult Pain - normal Reassure pt. Impaired verbal communication, Scenario #1 Clarify w/ Mrs. Martinez that she is asking if it is okay to resume sexual relations w/ her husband upon d/c. Reassess pain Ask pt. Safety- Reorient pt. Esteem- . Don clean gloves Remain with pt. Administer pain meds Psychological Needs - increased Acute Confusion: False Full assessment Vitals? Fall Risk: Increased acuity He also states he is feeling weak Pain, Acute: True Have an aide sit w/ Ms. Barkley while you obtain the IV supplies and notify the HCP of her declining condition. Encourage aggressive IS Dysfunctional gastrointestinal motility: False Report and document results Scenario #1 Provide emotional support Connect telemetry if it is okay exam 3. Scenario 1 Give ASA Scenario 3 2/23/22 VCBC Glucose Regulation Swift River #1 Dotty Hamilton Room 301 Dosage of metformin? Review medication orders for pain Sensorium - normal, - Acute pain Scenario 3 Scenario #2 Visual assessment Educate pt. Ms. Horton's wounds are now stable enough to be discharged home w/ the following orders 1.) Notify doctor Inspect pleurovac Empty foley bag Deficient knowledge: False Evaluate pt's understanding The surgeon added oxycodone 5mg q 4-6 hours prn pain. Orient pt and husband to the unit You have entered the room to administer the pts morning medication, atenolol 50mg. Fall Risk - increased Change dressing Assess airway Readiness for enhanced immunization status Scenario #5 Fall, risk for: True Orient patient to utensils and location of food on tray Hand hygiene Psychological Needs - normal Apply Silvadene You discuss this cough w/ Mr. Dominec to determine how long he has had it. administer new pain medications Scenario #2 Escort pt to ER for a physical and psychological evaluation Nausea Fear: True Pain Level - Increased Describe to pt. Check for cognition Offer to assist Attempt to establish rapport Describe the experimental evidence that DNA is the hereditary material of bacteriophages. She has well controlled hypertension with Losartan (Cozaar) 50 mg q daily. Administer antipyretic medication Check proper positioning Visual assess -Obtain witnesses to sign an advance directive Scenario 2 Assess I&O Reassess BP & P Obtain VS She is frustrated and overwhelmed with the new appliance not working properly. Contact hospice/social work Explain to Mrs. Whitmore Ineffective health maintenance: True Evaluate understanding Alert ICU Wash and glove Notify HCP Fall Risk: Increased acuity Document results Administer protocol antidirrheal medication Document results Hopelessness: True Mr. Raymond is stabilized w/ RRT. Explain to the pt. Scenario 4 Log roll pt. Assess for the abrupt Use therapeutic Orient pt. Give your answer as a percent and round to one decimal place when necessary: 27.4%81\frac{27.4 \%}{8 \cdot 1}8127.4%, (a) Calculate the osmotic pressure of the hemodialysis solution at 25C25^{\circ} \mathrm{C}25C. Scenario #3 Powerlessness: False Health Change - increased Identify the client Wash & glove Marcella is very worried about STD's and posssible pregnancy, Scenario 1 Ask if the pt. Ongoing debates? Post-op assessment Explain s/sx of wound infection. Esteem- Offer bedpan Notify lead RN Social isolation: True, Marcella Como Scenario 2 -Position the patient in high Fowlers if tolerated. Offer to contact family for HCP. Scenario 2 Ensure pressure dressing is in place Explain that he will probably not be going home at least until his Dr. sees him Impaired comfort: True -Tell the patient that dressing must be changed, 1-Put a mask on yourself Educate pt. VS are BP 80/40, P 46, R 16, (pt now intubated and ventilated by Respiratory Therapy), Scenario 1 Education of F/C procedure Esteem- LOC: Normal acuity Ask the patient when the advance directive was last updated Offer assistance You enter patient's room. Introduce hospital liaison, Acute pain Decisional conflict: False After 24 hrs, Ms. Gestalt fever and chills have subsided but now states she is feeling like her cast is too tight Head-to-toe Evaluate patient learning Full assessment Scenario #4 Allow family to remain Ms. Cumble states that she has not had a BM for three days SOLUTION: Dotty hamilton swiftriver docx - Studypool why you are doing Document results/findings Obtain & verify Pain - increased Swift River Joyce Workman scenario. Her husband who is present stats, "I thought it was just a lumpectomy she was having this morning." Disturbed personal identity: True Scenario 3 Ensure signed consent Using therapeutic Noncompliance: True Document Anticipate need Scenario #4 Impaired comfort Safety- Scenario #2 Tell the pt. Relocate pt. Have the pt. Provide for physical and thermal comfort Obtain 16 gauge angiocath Notify the HCP of absence of Advanced Directive and the families request to intubate. Label the sporophyte plant stages of the life cycle. Document all findings Scenario 4 Failure to Thrive True. Pain Level: Normal acuity Explained HIPPA protocol Swift River- Pediatrics. She shares her concerns about the pt's wife who is now coughing and having night sweats - Risk for physical injury Initiate secondary Assess pain -Gas exchange Explain to pt. Scenario #5 He refuses to comply with dietary recommendations. Evaluate understanding She was asymptomatic upon arrival. -IV Antibiotics Start O2 @ 2LNC Ask PCT She was admitted yesterday for stabilization of her glucose levels, and assist her with lifestyle modification. Explain to the wife Consult social services Report finding to HCP using SBAR. - Anxiety Impaired mobility: False Document results/findings ambulate Study with Quizlet and memorize flashcards containing terms like Tim Jones, Tim Jones, Tim Jones Scenario 1 You begin your shift assessment w/ Mr. Jones Scenario 2 Mr. Jones is scheduled for a full body CT scan. Remove IV & document Contact assisted living Bleeding, risk for Grieving: False Psychological Needs - increased Impaired tissue integrity: True Ask pt to explain to you what procedure she was expecting to have this morning. Scenario #2 Scenario 4 Inform his partner Scenario 1 Communicate w/ the pt therapeutically Encourage Mr. Jones What should be included in the A. Scenario 3 Secure help Post CVA, he has developed some aphasia and is having difficulty with verbal communication. - Ineffective health maintenance Apply fall risk bracelet What are your views, please? PT to educate 2-The patient was admitted yesterday and a newly diagnosed diabetic. Mr. Mancia is a non-English speaking pt and is fearful of being discovered as an illegal immigrant. Scenario 3 Restart the IV Pain - increased Mrs. Stukes's appliance is leaking for the fourth time today and has been changed and reapplied each time. Risk for physical injury: True Health Change - increased Discuss the policy Health Change - increased Receive handoff Pain - normal Scenario #3 Mr. Raymond continues to deteriorate and becomes confused. Contact surgeon - Impaired gas exchange Ms. Rails states that she has not had a bowel movement (BM) in the past two days. Scenario #3 Tell the pt. Med-Surg SR. 83 terms. Pain - normal Scenario 2 Scenario #5 Encourage to ambulate 4-Observe the complete respiratory cycle Report current urinary output quantify per hour and color of urine This is his second dose. Explain to Mr. Burgandy Give SBAR Fatigue: False Assess pt's pain -Reapply Silvadene and sterile dressings. Evaluate potential barriers Pain - increased Assess pain Inspect pt's abdomen 88 y/o female ID pt. Monitor and evaluate fluid intake She is oriented x3 but at times seems to be talking to someone in the room when no one is present. Scenario 3 Nutrition Ask Mrs. Workman to explain what she knows about diabetes. 2.) - Deficient knowledge Initial assessment Scenario #2 Scenario 5 Report this activity, Bleeding, risk for Impaired mobility Comfort the pt Fall, risk for Complete secondary Scenario 5 -Administer the hydromorphone hydrochloride Notify the HCP Scenario 2 Provide pt. Connect telemetry Psychological Needs: Increased acuity, Educational Needs: Increased acuity Apply O2 at 2LNC Auscultate lungs Inspect cast site Sign additional Prepare for external Grieving: False Skin integrity at risk Scenario #5 Joyce Workman Scenario 1 Mrs. Workman presented to the diabetes clinic and provided a 24-hour food recall. Assist w/ intubation, Educational - increased Educate pt Deficient knowledge Educate pt, - Educational Needs - increased Offer to the family Bring the family in Peripheral neurovascular dysfunction: False Deficient knowledge Scenario #2 Asses Mrs. Workman's knowledge She pulled out her IV and it will need to be restarted for her IV I pro dose that is due now. - Ineffective airway clearance Health Change: Increased acuity Perform post-op Acute pain: True Place personal aspirin Grieving Scenario 3 Assess Mr. Martinez's willingness to learn. : an American History, Physio Ex Exercise 8 Activity 3 - Assessing Pepsin Digestion of Proteins, Lesson 8 Faults, Plate Boundaries, and Earthquakes, EES 150 Lesson 2 Our Restless Planet Structure, Energy, & Change, Assignment Unit 8 - Selection of my best coursework, Logica proposicional ejercicios resueltos, Chapter 01 - Fundamentals of Nursing 9th edition - test bank, Focused Exam Alcohol Use Disorder Completed Shadow Health, Tina Jones Heent Interview Completed Shadow Health 1, Leadership class , week 3 executive summary, I am doing my essay on the Ted Talk titaled How One Photo Captured a Humanitie Crisis https, School-Plan - School Plan of San Juan Integrated School, SEC-502-RS-Dispositions Self-Assessment Survey T3 (1), Techniques DE Separation ET Analyse EN Biochimi 1. Inform the pt. 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. -Apply new probe cover to probe before assessing temperature Request repeat potassium lab Psychological Needs - increased Educate pt Scenario 3 Scenario #5 She has been documented as being obese, new onset hypertension, polyuria, and a rash on her abdomen. Check patency Document results joyce workman swift river quizlet joyce workman swift river quizlet Bleeding, risk for 2-The patient has survived a mass shooting Obtain blood (culture #2) -Assist patient in performing hand hygiene Day 2 admission, Thomas Richardson is complaining of severe pain and is now begging you for some relief; states pain scale 10/10 Swift River Dotty Hamilton scenarios; Swift River Jose Martinez scenarios; Blood Therapy lesson 2 post test; Blood Therapy Exam; HESI Case Study Sentinel Event Suicide; . Linda Pittmon Room 304 Glucose level? Ensure informed consent for procedures is signed Scenario #3 Announce, "CLEAR Obtain & fill Establish an IV The pt has now been sedated, and RT is temporarily maintaining their saturation's w/ effective valve mask ventilation. Provide SBAR Prepare pt. Explain the necessary procedure Don 2nd set of clean gloves to provide stump care. 2-Insert the indwelling urinary catheter She is super morbidly obese with a BMI of 52, Ht, 5'3", Wt, 293lbs. Complete initial Health Change: Increased acuity Encourage positioning Reassure pt. Psychological Needs: Normal acuity 500 mL NS Document, Educational - increased Upon entering the room, he asks if you have medication for "heartburn". -Reassure patient Have secretary Discuss support, Acute pain Ensure type and cross Request time she can arrive and staff to help w/ txf Health Change - increased Perform circulatory - Neurological - normal Instruct pt. hx Compromised family coping: True Scenario #4 Neurological: Normal acuity Documents all findings Scenario #5 Talk with Mr. Jones Scenario 3 She was asymptomatic upon arrival. Do not disturb Scenario #5 Assess for bowel The. Remove old dressing Perform initial Cultural competence Self-care deficit: False 7/3/2014 1 0 0 0 7/3/2014 100 0 0 0 0 0 1 1 0 0. nur104 Swift river scenarios Exams study guides . 6 terms. Scenario 4 Safety- Reassess pt's VS Could he have another heart attack? Scenario #4 They feel that you should share w/ them if he was a "real AIDS" pt or not. Disturbed sleep pattern: False Connect pt. -Assess radial and apical pulse for 60 seconds Current VS BP 110/70, P 94, pt is pale, dizzy and nauseated. Scenario 5 Scenario #5 -Inform healthcare provider that the advance directive was not completed, but one is being executed now Risk for injury, Scenario #1 Educate pt. Notify Dr if condition is abnormal Scenario 5 Document results and findings Psychological Needs - increased Provide comfort Fall Risk: Increased acuity She has well-controlled hypertension with Losartan (Cozaar) 50 mg q daily. Knowledge deficit: True Scenario 5 - Fall Risk - increased Ensure pressure dressing Document results Scenario #2 Health Change - increased Impaired mobility Scenario 5 Impaired comfort: True Reassess VS & elevate HOB statement Acute pain: True I am concerned about keto-acidosis and the complications of hyperglycemia. Evaluate pt's understanding Assess understanding through teach back Delay insertion of IV -Speak slowly in a normal tone of voice - Social isolation, risk for, Scenario #1 Continue to assist Scenario 5 Request repeat Provide initial Position the pt. Scenario 4 Call rapid response Pre-medicate for pain w/ prescribed medication Make sure O2 mask is secure and free of sputum. Reassure pt. - Sensorium - normal, - Acute pain He has been readmitted for a red spot on his sacrum of 1 cm and a 2 cm blister on his right heel. Scenario 5 - Fall ,risk for Deficient Knowledge: True Use therapeutic communication/Active Listening Risk for infection: True, Donald Lyles Sensorium: Normal acuity, Physiological- Collect stool Fall risk, Scenario #1 Educate pt. Ambulates with minimal assistance. Initiate IV Notify doctor -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 Fear Evaluate medication effectiveness Scenario #4 Leave the break room and not continue in conversation. As Ms. Horton is waiting by the exterior hospital door, construction workers are on the road working w/ a jackhammer. Don clean gloves to remove old dressing Wash hands Scenario #5 Upon entering the room, what is the appropriate order of events for the RN to take? Psychological Needs: Increased acuity Perform full assessment Administer antiemetic medication Stop the platelets Reassess pt's VS's and pain level Assess VS Remind staff that Universal Precautions are practiced at this hospital for all pts regardless of known ID's. impaired comfort - Fall, risk for 2-hrs later, Mr. Duncan is asked how frequent his stools have been today. Release restraints Pain Level: Normal acuity Provide emotional support Acute Pain: True 1 Ask for a copy of the advance directive Position the pt properly Impaired mobility, risk for -Reassess wound site Nutrition: True Scenario 2 Establish and IV line Wash/glove hands Document Clinical 2. -Inform the patient that he will have plenty of time to decide, and the Provider will discuss all the options with you Assist & support Fall Risk: Increased acuity Sensorium - normal, - Acute pain Ms. Monson has been in restraints f or the past two hours w/ a nursing assistant remaining w/ her. Bleeding - Psychological Needs - increased Impaired comfort Allow visitors to enter, Educational - increased The, patient is not on O2. Full assessment Scenario #2 Review plan Scenario #4 Scenario 1 Noncompliance, Scenario #1 Provide comfort measures Mr. Duncan's wife meets you in the hall asking what she could bring her husband to eat from home, Scenario 1 Offer masks D/C instruction Assess understanding ", Scenario 1 Remind Mr. Jones Assess stool Don new gloves Wash hands Impaired comfort Start PCA pump Scenario 4 Scenario 5 macyriley1. Scenario 1 Begin fluid and electrolyte Orient Roger Scenario #5 Imbalanced Nutrition: False Impaired comfort post MI Fall Risk: False Self-care deficit: True Notify HCP Isolation Precaution: False Joyce Workman, Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. The pt continues to be combative while attempting to initiated the CPAP trial. Encourage fluids Scenario 3 Kenny Barrett Full assessment This morning, at shift report, she states that she is scared to leave the hospital after the shooting incident. Joyce Workman Room 302 Joyce Workman, a 42-year-old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Present health assessment Her HbA1C is. Assess Ms. Horton's orientation Psychological Needs - increased, Acute pain Take VS of protocols Document Scenario 5 Call HCP for change in health status and receive orders for anxiety medication Impaired home maintenance mgmg r/t client or family: False Review new orders Pain - increased NrsSR22. -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", -Comfort - Health Change - increased Asses pt. Psychological Needs: Normal acuity, Physiological- Wash & glove - Health Change - increased -Perfusion Scenario 2 Educate pt Obtain translator Employ therapeutic communication: present reality Notify charge RN Spiritual distress: False Notify lead nurse/Dr Scenario 3 Assess stress level Acute confusion Order a new clear Explain to Mr. Greer Educate pt. Scenario 5 Ms. Horton did not rest well last night, and woke up frequently w/ episodes of crying. Assess pt's understanding, Bleeding, risk for Fatigue: True Notify Infection Control 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. Initiate IV heparin Scenario #3 Fall, risk for: True Ensure the bed Scenario 1 Infection, Scenario #1 Impaired Skin Integrity, Risk for: False Notify Dr. of change Scenario 1 -Orient patient to bathroom with specifics Scenario 2 Pain - increased Repeat 1mg of Atropine administration w/in 3-5 minutes of first dose - Neurological - increased Place the syringe in a biohazard bag and place a pt id label on bag Donald Lyles 5. Establish when the cardiac Scenario #4 Health Change - increased -Check for color perception Set-up Obtain an order Ensure cardio-pads are in place anterior chest and posterior back Scenario 2 Complete full assessment Dressing change q 24 hours to RT thighs and rt shoulder. Psychological Needs - normal Ensure chest tube, Educational - increased Introduce yourself Scenario #4 Order for a Foley catheter has been obtained and Lucy Jones, LPN, is their to assist. Scenario #3 Adjust rate of IV Fall Risk - normal Bleeding, risk for Reassess pt. Pain, Acute: False Impaired tissue perfusion: True - Health Change - increased Ask pt. Psychological Needs - Increased, Defensive coping Attempt to orient Provide operative summary of type of procedure, IV fluid and pain status. Ineffective health maintenance: True The labs return w/ digoxin level of 10.5 ng/mL, K 5.3 mEq/L. Request sitter Before entering Carlos Mancia room to administer his antipyretic medication for his recent temp of 101.2 Chronic Pain: False Continue to provide Fall, risk for -Provide PRN pain medications indicated. Assess pain and rhythm Q15 minutes Fall Risk: Increased acuity In reassessing Ms. Monson, her VS are BP 106/82, T 98.2, P 106, R 18, SaO2 88, Scenario 1 condition - Health Change - increased Apply fall risk 1-Introduce yourself to the patient and explain who you are