Fundamentals swift river with complete solution
Donald Lyles, 52-year old male, was admitted yesterday evening for stabilization
of his uncontrolled type II diabetes. His HbgA1c is 10.6%. He has a history of a
Myocardial Infarction, MI, one year ago, and has refused all cardiac rehab, and
has not had another cardiac event. He refuses to comply with dietary
recommendations. His BMI is 37. Vital signs are BP: 146/94, P: 88, R: 22, T: 99.2,
PaO2: 94% Blood glucose upon admission is 340 mg/dl
Glucose regulation
Nutrition
safety
1Engage Safety
Dispose syringe in sharps container
2Use unexpired glucometer strips
Verify patient identity
3Assist patient in leaving the room
Activate fire alarm
Contain the fire
4Assess for obvious injury
Notify HCP of fall
Obtain vital signs
5Complete an incident report and submit to risk management
Document in nurses' notes fall event and patient status
Kenny Barrett, 64 years old, was admitted for observation of initial administering
of BP his treatment with blood pressure of 220/124 after visiting his doctor for a
routine physical. ECG was unremarkable. No past history of HTN. Past medical
history includes hyperlipidemia, current elevated triglycerides, and a history of 1
pack a day smoker for the past 20 years. Vital signs are Temp 98.9F, BP 178/90, P
88, RR 18 SaO2 95% on Room air. IV with NS @ 125 mL/ hr. Patient has been
complaining of a headache and dizziness. He is a patient of Dr. Adams.
Addiction
perfusion
Linda Yu, was admitted to your unit after surgery on her left hip due to a fall. She
is 2 days post-op. She is 85 years old and has a history of osteoarthritis and
cataracts. PT has been getting the patient up with a walker and she is able to take
a few steps. She is aware of herself and the situation, but no time or day. She is
also anxious as a result of recent surgery. Her family lives out of state, but the
daughter was here for the surgery, she left yesterday. The plan is to discharge
Ms. Yu back to her assisted living facility. Her daily medications at home include:
Prednisone 5 mg, Furosemide 20 mg, and ASA 81 mg daily. The surgeon added
oxycodone 5mg q 4-6 hours prn pain. NKDA.
, Anxiety
care coordination
stress and coping
Preston Wright, 73-year-old male patient of Dr. Greene, status post CVA 4 weeks
ago. He has been readmitted for a red spot on his sacrum of 1 cm and a 2 cm
blister on his right heel. IV fluids of D5 1/2 NS are infusing at 100 mL/hour to his
right forearm. Mr. Wright is pleasant and cooperative but needs to be reminded to
avoid pressure on his heel and sacrum. Post CVA, he has developed some
aphasia and is having difficulty with verbal communication. He has orders for
dressing changes q daily and pain medications before the dressing change.
Cognition
communication
mobility
sensory perception
Donald Lyles Scenario 1
You are administering Insulin for Mr. Lyles. What do you do with the needle
immediately after injecting the patient?
Scenario 1
Dispose syringe in sharps container
Engage Safety
Scenario 2
Use unexpired glucometer strips
Verify patient identity
Scenario 3
Assist patient in leaving the room
Activate fire alarm
Contain the fire
Scenario 4
Notify HCP of fall
Assess for obvious injur
Obtain vital signs
Scenario 5
Complete an incident report and submit to risk management
Document in nurses' notes fall event and patient status
Kenny Barrett Scenario 1
When reviewing your patients' vital signs, taken by the UAP, you notice Kenny
has a blood pressure of 190/110 and a pulse of 105. What actions by the nurse are
appropriate?
1-Reassess blood pressure and pulse
-Educate UAP regarding notification of abnormal range of vital signs
2-Current elevated BP
Donald Lyles, 52-year old male, was admitted yesterday evening for stabilization
of his uncontrolled type II diabetes. His HbgA1c is 10.6%. He has a history of a
Myocardial Infarction, MI, one year ago, and has refused all cardiac rehab, and
has not had another cardiac event. He refuses to comply with dietary
recommendations. His BMI is 37. Vital signs are BP: 146/94, P: 88, R: 22, T: 99.2,
PaO2: 94% Blood glucose upon admission is 340 mg/dl
Glucose regulation
Nutrition
safety
1Engage Safety
Dispose syringe in sharps container
2Use unexpired glucometer strips
Verify patient identity
3Assist patient in leaving the room
Activate fire alarm
Contain the fire
4Assess for obvious injury
Notify HCP of fall
Obtain vital signs
5Complete an incident report and submit to risk management
Document in nurses' notes fall event and patient status
Kenny Barrett, 64 years old, was admitted for observation of initial administering
of BP his treatment with blood pressure of 220/124 after visiting his doctor for a
routine physical. ECG was unremarkable. No past history of HTN. Past medical
history includes hyperlipidemia, current elevated triglycerides, and a history of 1
pack a day smoker for the past 20 years. Vital signs are Temp 98.9F, BP 178/90, P
88, RR 18 SaO2 95% on Room air. IV with NS @ 125 mL/ hr. Patient has been
complaining of a headache and dizziness. He is a patient of Dr. Adams.
Addiction
perfusion
Linda Yu, was admitted to your unit after surgery on her left hip due to a fall. She
is 2 days post-op. She is 85 years old and has a history of osteoarthritis and
cataracts. PT has been getting the patient up with a walker and she is able to take
a few steps. She is aware of herself and the situation, but no time or day. She is
also anxious as a result of recent surgery. Her family lives out of state, but the
daughter was here for the surgery, she left yesterday. The plan is to discharge
Ms. Yu back to her assisted living facility. Her daily medications at home include:
Prednisone 5 mg, Furosemide 20 mg, and ASA 81 mg daily. The surgeon added
oxycodone 5mg q 4-6 hours prn pain. NKDA.
, Anxiety
care coordination
stress and coping
Preston Wright, 73-year-old male patient of Dr. Greene, status post CVA 4 weeks
ago. He has been readmitted for a red spot on his sacrum of 1 cm and a 2 cm
blister on his right heel. IV fluids of D5 1/2 NS are infusing at 100 mL/hour to his
right forearm. Mr. Wright is pleasant and cooperative but needs to be reminded to
avoid pressure on his heel and sacrum. Post CVA, he has developed some
aphasia and is having difficulty with verbal communication. He has orders for
dressing changes q daily and pain medications before the dressing change.
Cognition
communication
mobility
sensory perception
Donald Lyles Scenario 1
You are administering Insulin for Mr. Lyles. What do you do with the needle
immediately after injecting the patient?
Scenario 1
Dispose syringe in sharps container
Engage Safety
Scenario 2
Use unexpired glucometer strips
Verify patient identity
Scenario 3
Assist patient in leaving the room
Activate fire alarm
Contain the fire
Scenario 4
Notify HCP of fall
Assess for obvious injur
Obtain vital signs
Scenario 5
Complete an incident report and submit to risk management
Document in nurses' notes fall event and patient status
Kenny Barrett Scenario 1
When reviewing your patients' vital signs, taken by the UAP, you notice Kenny
has a blood pressure of 190/110 and a pulse of 105. What actions by the nurse are
appropriate?
1-Reassess blood pressure and pulse
-Educate UAP regarding notification of abnormal range of vital signs
2-Current elevated BP
