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Swift River- ATI| 66 Questions &
Answers 100% Correct!!
Arthur Thomason 56-year-old MVA victim, fourth day post op with a splenectomy and femur repair. He is experiencing new onset of shortness of breath and has a nasal cannula with 2L of Oxygen in place. He is restless with slight confusion but is easily orientated with attempts from nurse. Temperature spiked during the night to 102.4, BP now 146/94 which is slightly elevated, respirations at 30 bpm and slightly labored, heart rate 102 versus 84 from last night shift. Skin cool to touch and appears pale. His coughing, to clear his airway, appears ineffective. Recent chest X-ray shows diffuse bilateral interstitial infiltrates in all lobes. Recent blood gases demonstrate falling PaO2 (hypoxemia) and increasing CO (Hypercapnia). Mr. Thomason is anxious and is obviously worsened from the shift before in overall condition. - ANSWER-Alteration in comfort: True Alteration in gas exchange: True Ineffectual airway clearance: True Potential for shock: True Prolonged confusion: True Anxiety/fear: True Potential for failure to thrive: True Donald Lyles 52-year old male, was admitted yesterday evening for stabilization of his uncontrolled type II diabetes. He is married, and his wife is requesting to stay at his side. 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 - ANSWER-Select appropriate nursing concerns below based upon patient report above: Acute discomfort False Alteration in comfort False Knowledge Deficit True Nausea False
Potential for falls False Potential for infection True Estelle Hatcher Estelle Hatcher 31yr-old, r/o appendicitis, 1st day post-op appendectomy; No known allergies (NKA); Vital signs - Temp 101.2, BP 108/74, P 92, RR 20, SaO2 99%, alert and cooperative. Wound site clean, dry and intact NPO, NG-tube to low continuous suction. IV maintenance fluids with D5 1/2 NS with 20 KCL @ 125ml/hr in left forearm. Ambulates with minimal assistance. Family at beside. Dr. Sangerstien - ANSWER-Select appropriate nursing concerns below based upon patient report above: Physiological Acute discomfort False Alteration in bowel elimination: diarrhea: false Alteration in comfort: true Alteration in mobility: true Decreased activity tolerance: false Potential for alteration in electrolyte balance: true Safety Fear: false Ineffectual self-health management: false Knowledge deficit: true Potential for falls: true Potential for infection: true Sleep deficit: false 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. - ANSWER-Acute discomfort False
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. Brown
- ANSWER-Select appropriate nursing concerns below based upon patient report above: Physiological Acute discomfort F Decrease in fluid volume F Electrolyte Imbalance T Ineffectual renal perfusion, risk for T Potential for alteration in skin integrity: F Potential for imbalanced fluid volume: T 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. - ANSWER-Select appropriate nursing concerns below based upon patient report above: Physiological Acute discomfort: T Alteration in nutrition: F Alteration in urinary elimination: T Safety Acute Confusion: T Disturbed Sensory Perception: F Potential for falls: T Sleep deficit F
Love and belonging Anxiety: F Failure to Thrive: T Safety Grief F Peripheral neurovascular dysfunction F Potential for falls T 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. - ANSWER-Select appropriate nursing concerns below based upon patient report above: physiological Alteration in communication F Alterations in bowel elimination: constipation F Ineffectual airway clearance F Ineffectual breathing pattern F Potential for acute discomfort T Potential for alteration in physical mobility T Potential for alteration in tissue integrity T Potential for altered body image T Potential for imbalanced nutrition F Safety Isolation Precaution F
this morning. Diet as tolerated. - ANSWER-Select appropriate nursing concerns below based upon patient report above: Physiological Acute discomfort T Alteration in mobility F Alteration in urinary elimination F Readiness for Enhanced Immunization Status T Sarah Kathryn Horton 25 -year old graduate student was brought to the emergency room via ambulance after being shot on the local college campus. Sarah was admitted to Med-Surg at 2am. She has two through and through gun-shot wounds. One to her right thigh and one to her right shoulder. She has a 20- gauge peripheral IV to left forearm with 75 mL/hr. of 0.9% saline infusing. Vital signs are stable at this time, alert and oriented x3, reports pain 6/10. She remains tearful and has been told that her best friend died on the scene. - ANSWER- Select appropriate nursing concerns below based upon patient report above: Physiological Acute discomfort T Alteration in body image F Alteration in physical mobility T Alteration in skin integrity T Anxiety T Disturbed self-identity T Exhaustion F Potential for decreased oxygenation F Potential for post trauma syndrome T Safety Alteration of Protective Mechanisms T Keaton Henderson 42-year-old, male police officer in the neighboring city. He was shot, off- duty 2 days ago, trying to intervene in an armed robbery at the gas station. He has had a right thoracotomy and has a D5W at 125 an hour. He was transferred to the floor late yesterday evening. He has GSW to right side of chest. His vital signs upon admission to the floor were BP 140/72, HR 78, T 98.4 F, 36.9 C, R 20, PaO2 96% room air. He has a 3- chamber water-seal chest drainage system at low continuous suction with minimal drainage.
His last chest x-ray shows his right lungs to be fully expanded, and the plan is to remove the chest tube in two days. - ANSWER-Select appropriate nursing concerns below based upon patient report above: Physiological Acute discomfort T Alteration in comfort T Nausea F Potential for bleeding T Safety Fear T Grief T Potential for falls F Potential for infection T Prolonged confusion F Sleep deficit F Love and belonging Alteration in body image F Anxiety T Chronic sadness F Impaired family coping T Loss of power F Socially isolated T Esteem Decisional Conflict F Ineffectual coping T Noncompliance F Sexual assault trauma syndrome T
You enter room one hour after the physician has left the patient. Your notice Mr. Thomason is lying supine, appears slightly cyanotic in his lips, is exhibiting more effort to breathe, and is increasingly restless. Lung sounds are worse. Drag the following actions into the correct order. (The first item should be on top.) - ANSWER-1Tap patient and ask, "Are you okay?" 2Elevate head of bed 3Call Rapid Response team 4Start secondary large bore IV line 5Remain with patient and reassure Arthur Thomason Scenario 4 Rapid Response team arrived including anesthesia. The MD on site makes the decision to intubate the patient and start ventilatory assistance and move the patient to Respiratory Intensive Care. Drag the following actions into the correct order. (The first item should be on top.) - ANSWER-1Provide verbal report to team members who respond to rapid response 2Emergency intubation and assisted breathing is provided for Mr. Thomason 3Assume role in response team of documenter 4Obtain patient record and follow patient as he is transferred to ICU 5Provide information for MD to call family at home and explain what has just happened Arthur Thomason Scenario 5
The family arrives one hour after the event to his prior room and find Mr. Thomason's room is empty and have no idea of the events that have just occurred. You, his prior nurse, notice the family and respond to them. - ANSWER-1You explain that his condition has worsened and now he has been taken to ICU.SBAR communicates Situation, Background, Assessment, Recommendation. 2You explain that he is receiving a higher level of care and was he was sedated before leaving the floor to make him more comfortable. 3You have them remain with you, seated in comfortable place, while you call ICU and attempt to locate physician for them. 4You escort them with you to the ICU. 5You call his doctor to inform him the family has arrived. Charlie Raymond Scenario 1 The 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 125/78, Pulse 102, Respirations 30 and labored, Temperature 101.3, SaO2 91%. He has bilateral lower lobe atelectasis with bronchial/vesicular wheezing. - ANSWER-1Don appropriate PPE.Per CDC guidelines. 2Change to simple O2 face mask per Healthcare provider. 3Perform focused respiratory assessment. 4Notify respiratory therapist to begin treatment 5Notify family to self-isolate for 14 days. Charlie Raymond Scenario 2 Mr. 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. - ANSWER-1Reorient patient to setting using therapeutic communication.
2Ensure patient is in fowlers position.Respiratory status is less compromised in a fowler's position. 3Check the foley catheter to make sure it is not obstructed.Ensure accurate output. 4Notify Rapid Response team (RRT).Deteriorating condition necessitates immediate intervention by RRT. 5Provide 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: Drag the following actions into the correct order. - ANSWER-1Mr. Raymond, COVID- 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. Donald Lyles Scenario 1 Mr. Lyles calls you via the call light. Upon entering the room, he asks if you have medication for "heartburn". He says, "I take TUMS at home when this happens." You tell the patient you will be glad to check-on what is available for relief of his "heartburn" after you complete his physical assessment. You begin his assessment, and he falls back in the bed and becomes unresponsive. You shout, "Are you okay? Are you okay?" - ANSWER-1Establish responsiveness.Determine neurological status.
2Call for Rapid Response/CODE-blue.To receive help to assist with resuscitation immediately. 3Check for breathing and carotid pulse.To ensure that CPR is indicated. 4Begin continuous chest-compressions until help arrives.Per ACLS protocol for resuscitation. 5When help arrives, pass off chest compressions and begin respirations.In order to maintain physical stamina. Donald Lyles Scenario 2 The CODE-blue team arrives with a crash cart, Physician, Anesthetist, and 2 critical-care nurses, and 1 Respiratory therapist. - ANSWER-1Assist with airway management.Airway is the priority to ensure the patient is properly ventilated and the airway is protected from aspiration. 2Assist with applying ECG leads.Assess rhythm to see what treatment is indicated. 3Establish large IV access.IV access must be established for rapid medication administration. 4Provide patient history of event to team.In order to facilitate in establishing the etiology of the cardiac event. 5Provide medical history - including medication history and allergies.To assess for medication interactions, and information is necessary for proper treatment. Donald Lyles Scenario 3 You have now been assigned to document the ongoing event as the CODE team continues with the resuscitation. - ANSWER-1Check time from one source.Ensure accurate and consistent time progression. 2Establish when the cardiac event time began.Important to determine how long resuscitation efforts to establish length of Hypoxia.
3Repeat 1mg of Atropine administration within 3-5 minutes of first dose.Established ACLS protocol for treatment of bradycardia as first dose was ineffective. 4Prepare for external pace-maker placement.Emergency treatment for bradycardia due to heart block when Atropine is ineffective. 5Document and accompany patient to ICU immediately, and handoff report to receiving ICU nurse.To ensure continuity of care and accurate SBAR. Estelle Hatcher Scenario 1 Estelle HatcherMs. Hatcher is second day post-op and has a nasogastric tube set to gravity drainage only. She presses the call light with questions about who her nurse will be and has concerns about her NG-tube - ANSWER-1Introduce Yourself/Identify PatientIntroduction and identification are the first steps. 2Full AssessmentEstablishing baseline and identifying areas of concern will need to be completed in order to educate patient. 3Provide ComfortPerform based on information attained from patient discussion and assessment. 4Educate PatientHelps patient understand circumstances of treatment concerning NG Tube. 5Evaluate UnderstandingImportant to follow education up with evaluation for effective patient care. Estelle Hatcher Scenario 2 During the follow up nursing assessment, Ms. Hatcher complains about the nasogastric tube causing her pain in her nasal area. She has active bowel sounds. ASSISTANCE REQUESTED You hear a patient screaming, "I do not want any more visitors." Select action...Please waitRequest an RNRequest an LPNRequest a CNASUBMIT Available staffRNs:2LPNs:0CNAs: Drag the following actions into the - ANSWER-1 Wash/Glove Hands First step in patient assessment/intervention. 2 Inspect Pain Location Assessment first step in Nursing Process.
3 Check Proper Positioning Intervention is second step in Nursing Process. 4 Discuss with patient about notifying Doctor for possible Removal of NG Tube. This lets patient be involved in plan of care 5 Verify Call Light/Bed Safety precautions After patient care, always place call light in reach and bed in lowest position. Estelle Hatcher Scenario 3 Estelle HatcherDr. Brown gives orders to remove nasogastric tube set to gravity and to begin a clear liquid diet. - ANSWER-1 Educate patient of procedure Before performing procedure, inform patient. 2 Evaluate Understanding Make sure patient understands information given. 3 Remove NG-Tube by elevating head of bed, instruct patient to exhale slowly while withdrawing NG Tube. After education and evaluation patient is ready for Procedure. These steps minimize risk of aspiration. 4 Order a new clear liquid diet New clear liquid diet order can be started. 5 Document Results Accurate documentation is to be performed after patient care is performed, NEVER BEFORE! Estelle Hatcher Scenario 4 Mrs. Hatcher appears restless, diaphoretic and calls the nurse for help. Upon entering the room, what is the appropriate order of events for the nurse to take? - ANSWER- Wash/Glove Hands First step in patient assessment/intervention. 2 Full Assessment Assessment is first step in Nursing Process. 3 Encourage Incentive Spirometry Increasing oxygen levels is a proper intervention. 4 Reassess patient Assessment evaluates the effectiveness of the Incentive Spirometry Intervention. 5 Document Results Accurate documentation is to be performed after patient care is performed, NEVER BEFORE! Estelle Hatcher Scenario 5 Estelle HatcherSeveral hours later, Mrs. Hatcher is feeling much better. She puts on her call light and asks to see a nurse. Upon entering the room, she asks you if she will be able to drive when she gets home tomorrow. - ANSWER-1 Use therapeutic communication/Active Listening Assessment is first using correct Therapeutic Communication technique. 2 Educate Patient Planning/Intervention is second/third step in Nursing Process. 3 Evaluate Understanding Performed after education. 4 Verify Call Light/Bed Safety precautions After patient care, always place call light in reach and bed in lowest position.
Keaton Henderson Scenario 4 RRT arrives and they diagnose right tension pneumothorax evident by severe mediastinal shift and tracheal deviation, hypoxia, and absent right sided lung sounds. A portable stat chest x-ray has been ordered, and the RRT calls for a thoracotomy tray and 36 F chest tube. The HCP asked for a 16-gauge angiocath to perform an emergency decompression of the right thoracic pressure - ANSWER-1 Obtain a 16-gauge angiocath Needed temporarily relieves pneumothorax tension and prevent cardiac arrest 2 Explain to the patient the plan of care, and that the procedure may be painful In order to allay anxiety of impending anxiety, and assist with patient cooperation 3 Set-up sterile thoracic tray for chest tube insertion, and prep the chest tube site A sterile field is required to prevent infection 4 Obtain and fill a new chest drainage system and Vaseline-gauze dressing Must have a properly sealed chest tube and Vaseline-gauze in order to promote airtight seal at insertion site 5 5 Assist with new chest tube insertion, maintaining sterile chest tube connections The connections between the chest tube and suction drainage must be connected using sterile technique in order to prevent infection Keaton Henderson Scenario 5 The 16-gauge needle insertion has relieved the pressure. The patient has stabilized and has had the new chest tube inserted. Nursing care should be: - ANSWER-1 Assess vital signs Hemodynamic assessment post insertion 2 Auscultate all lung fields To ensure the new chest tube insertion has re-expanded the affected lung 3 Complete stat portable chest x-ray To ensure the lungs are inflated bilaterally and the chest tube is in the proper placement 4 Inspect insertion site and ensure no leakage of blood/air To determine baseline assessment of new wound site 5 Ensure chest tube is closed to water seal, connections are taped, and the chest drainage system is below chest level In order to prevent complications, maintain patency, and ensure proper chest drainage system function Sarah Getts Scenario 1 Ms. Getts is requesting water to drink. Her pitcher has already been filled three times this shift. - ANSWER-1 Wash and glove hands First step in patient assessment/intervention. 2 Full assessment Refer to Nursing Process- Assessment, Planning, Intervention, Evaluation 3 Monitor and evaluate fluid intake Hydration or retention concern due to increased thirst. 4 Educate patient Education is to be achieved after understanding patient condition.
5 Document results Accurate documentation is to be performed after patient care is performed, NEVER BEFORE! Sarah Getts Scenario 2 Three hours later, Ms. Getts is unsteady when standing by her bedside. - ANSWER-1 Wash and glove hands First step in patient assessment/intervention. 2 Full assessment Change in condition warrants full assessment. 3 Apply fall risk bracelet Notifies staff of patient fall risk enhancing patient safety. 4 Document results Accurate documentation is to be performed after patient care is performed, NEVER BEFORE! Sarah Getts Scenario 3 You observe Ms. Getts being assisted by another nurse who is being blatantly rude and disrespectful to her. - ANSWER-1 Offer assistance Patient advocate is priority. 2 Remain with patient Provide safety and comfort to patient. 3 Therapeutic Communication Demonstrates caring to patient. 4 Notify lead nurse Team Lead should be notified. 5 Document results Accurate documentation is to be performed after patient care is performed, NEVER BEFORE! Sarah Getts Scenario 4 Ms. Getts is now complaining of sudden sharp, substernal chest pain, very short of breath and is profusely diaphoretic. - ANSWER-1 Visual assess Assessment is the first step of nursing process. 2 Call rapid response Patient assistance is number one priority. 3 Apply oxygen ABC's priority. 4 Establish second IV Proactive for possible heart cath lab visit. 5 Remain with patient Provides security for patient. Sarah Getts Scenario 5 Sarah GettsMs. Getts is being transferred as an emergency to Critical Care. Your responsibilities are: - ANSWER-1 Give verbal report To give proper report remember SBAR: Situation, Background, Assessment, Recommendation. 2 Escort patient Most HCP require RN to escort patients to UCI units. 3 Notify family Patient is priority; now update family to patient's location and status.
