PRIORITY Patient Activity
Part I: Who does the nurse see first?
Suggested Answer Guidelines
Herbie Saunders, 62 years old David Mueller, 71 years old Gladys Parker, 92 years old
CHF Exacerbation Below-the-Knee Amputation Weakness and Falls
NCLEX Client Need Categories Percentage of Items from Each Covered in
Category/Subcategory Case Study
Safe and Effective Care Environment
Management of Care 17-23%
Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12%
Psychosocial Integrity 6-12%
Physiological Integrity
Basic Care and Comfort 6-12%
Pharmacological and Parenteral Therapies 12-18%
Reduction of Risk Potential 9-15%
Physiological Adaptation 11-17%
Part I-Patient Care Scenarios
You are the RN on a busy medical-surgical/telemetry floor at Anytown General
Hospital. Each nurse on your unit typically cares for 3-5 patients.
You have just arrived for your day shift and are receiving nurse-to-nurse reports
from three different night shift nurses. After you receive reports, you will have
an opportunity to review the current orders for each of your patients.
NOC Nurse Report
Patient #1: Herbie Saunders
Patient Report: What Do You Notice? Clinical Significance:
“Herbie Saunders is a 62-year-old male who came Abnormal lung Crackles indicate that air is
in last night for a CHF exacerbation. His doctor is sounds: crackles in moving through fluid or
Dr. Davis and he’s a full code. He’s alert and bases secretions.
oriented and can make his needs known. He’s on
tele, normal sinus rhythm with occasional PVCs.
His pressures are fine, heart rate is in the 70s.
Lungs are clear in the uppers with crackles in the Coughing up white Coughing up excess fluid is one
bases. He’s coughing up a small amount of white frothy secretions. way the body attempts to
frothy secretions. He’s been on room air since he remove it from the lungs.
arrived, oxygen sats are in the low-mid 90s. He got
40 mg IV Lasix last night in the ED; I think you
might have something scheduled during your shift The patient is receiving Patients receiving diuretics
but I haven’t given anything overnight. He has a 20 IV diuretics. are at risk for hypotension,
gauge in his right forearm. I’m not sure how he nephrotoxicity, and electrolyte
gets around since he’s been in bed since he got imbalances.
here.”
Most Recent Vital Signs @ 0357 What Do You Notice? Clinical Significance:
T: 98.6 F (oral) These vital signs are all The patient’s vital signs are
within normal limits. stable.
P: 76
R: 20
BP: 128/87 (MAP 101 mmHg)
O2 sat: 92% on room air
Pain: denies
Admission Weight: 196 lb (89.1 kg)
In one sentence, describe the ESSENCE of the patient scenario that will guide your plan of care?
This patient is here for CHF exacerbation, which means that he is fluid overloaded and will require diuresis to
remove the excess fluid.
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