Nightigale Swift River Questions and Answers 100% Accurate
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Module
Nightigale Swift River
Institution
Nightigale Swift River
Nightigale Swift River Questions and Answers 100% AccurateNightigale Swift River Questions and Answers 100% AccurateNightigale Swift River Questions and Answers 100% AccurateNightigale Swift River Questions and Answers 100% AccurateNightigale Swift River Questions and Answers 100% Accurate
Carlos ...
Nightigale Swift River Questions and Answers
100% Accurate
Carlos Mancia
Carlos Mancia 48yr-old, Spanish speaking migrant worker with no known past medical Hx. r/o
Tuberculosis. Vital signs -Temp 99.1, BP 124/62, P 77, RR 20, SaO2 91%. Airborne Isolation. Neuro
WNL. Skin moist, respiratory bilateral wheezes and rhonchi. Blood-tinged mucous, productive cough.
Diet as tolerated. IV maintenance fluids with D5 1/4 NS @ 150 ml/hr X 3 then reduce rate to 75
ml/hr. Expresses fatigue, fear, concern, and desire for recovery. Need frequent reminder to stay in
room and maintain mask precautions. If family/visitors come, will need education to airborne
precautions. Spanish interpreter available at extension 61178. Dr. Rondeau - ANSWER-Physiological
DescriptionYour ResponseExplanationAlteration in gas exchange TrueStatus assessment reports
patient with increased secretion.Alteration in gastrointestinal motility FalseStatus assessment reports
no indication of nursing concern.Alteration in mobility FalseStatus assessment reports no indication
of mobility issues.Electrolyte Imbalance FalseStatus assessment reports no indication of electrolyte
imbalance.Exhaustion TrueStatus assessment reports patient expresses fatigue.Ineffectual airway
clearance TrueStatus assessment reports patient with increased secretion.
Safety
DescriptionYour ResponseExplanationAlteration in home maintenance management FalseStatus
assessment reports no indication of this nursing dx.Anxiety TrueStatus assessment reports patient
has fear and concerns.Decreased body temperature FalseStatus assessment exhibits signs for fever
not hypothermia.Fear TrueStatus assessment reports patient expresses fear.Knowledge deficit
TrueStatus assessment reports patient needs reminder to wear mask.Potential for falls FalseStatus
assessment reports patient connected to IV line and as being fatigued which could result in fall.
Love and belonging
DescriptionYour ResponseExplanationChronic sadness FalsePatient may be experiencing ACUTE
sorrow r/t recent medical diagnosis.Potential for becoming socially isolated TrueStatus assessment of
'if family/visitors come' and being placed on airborne precautions.
Esteem
DescriptionYour ResponseExplanationDecisional Conflict FalseStatus assessment reports no
indication of decisional conflict.Noncompliance TrueStatus assessment reports patient needs
reminders to wear mask.
Self-actualization
DescriptionYour ResponseExplanationReadiness for improved self-care TrueStatus assessment
reports patient desire for recovery.Spiritual difficulties FalseStatus assessment reports
, Charlie Raymond Scenario 4
UAP reports urinary output of 50 mL over the past three hours. Vital Signs: BP is 92/58, Pulse 102,
Respirations 32 and labored, Temperature 102.3, SaO2 90% 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 - ANSWER-You correctly ordered 5 out of
5 actions:
Your orderCorrect orderStepExplanation 11Make sure O2 mask is secure and free of
sputum.Maintain proper function of mask, sputum could cause mask to be less effective. 22Ensure
patient is in fowlers position.Respiratory status is less compromised in a fowler's position. 33Check
the foley catheter to make sure it is not obstructed.Ensure accurate output. 44Notify Rapid Response
team (RRT).Deteriorating condition necessitates immediate intervention by RRT. 55Provide initial
report and assist RRT.RRT needs immediate information on history/condition of patient.
Charlie Raymond Scenario 5
Mr. Raymond is stabilized with RRT. Give an SBAR to Hospitalist: - ANSWER-You correctly ordered 5
out of 5 actions:
Your orderCorrect orderStepExplanation 11Mr. Raymond, COVID-19 positive, in severe respiratory
distress, rapid response called.According to SBAR: Situation.
2Patient 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.According to SBAR: Background.
3Intubated by RRT, BP: 88/58, P: 110, T: 101.2, SaO2: 94%, ABG's are pending. Foley catheter in
place.According to SBAR: Assessment.
4Recommend patient be transferred to ICU.According to SBAR: Recommendation.
5Accompany your patient to ICU and give report to receiving nurse.To ensure adequate nursing
handoff.
Patient is scheduled for an Echocardiogram and MRI this AM. You are entering the room for the first
time. After performing hand hygiene and introducing yourself to patient, you should: - ANSWER-You
correctly ordered 5 out of 5 actions:
Your orderCorrect orderStepExplanation
1Perform initial assessment.Initial assessment is needed to baseline data.
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