Nightigale Swift River Questions and Answers 100% Accurate!
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Nightigale Swift River
Institution
Nightigale Swift River
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 cou...
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
, 1Perform initial assessment.Initial assessment is needed to baseline data.
2Ask the patient if she has had the procedures previously.To establish if the patient is claustrophobic.
3Ask the patient about any metal in or on her body.Metal on the body must be removed, if in the
body MRI cannot be performed.
4Ask if the patient understands the procedures scheduled for this AM.To reduce anxiety and
encourage compliance with procedures.
5Ensure informed consent for procedures is signed.Informed consent is required for these
procedures and the nurse's role is to serve as a witness.
ulia Monroe Scenario 2
The diagnostic tests were completed, and Dr. Gray has informed the patient of the diagnosis of Heart
failure and will be treated with digoxin. Upon entering the room, the patient is crying and asks when
will the medication fix her heart. - ANSWER-You correctly ordered 5 out of 5 actions:
Your orderCorrect orderStepExplanation
1Comfort the patient.Patient needs to be comforted as she just received her diagnosis..
2Provide education regarding heart failure.To explain heart failure is treatable and a normal lifestyle
is possible.
3Explain the treatment plan for the patient.Medication will not fix the heart, but will treat the signs
and symptoms.
4Evaluate patient understanding.To assess if the patient understood the education provided.
5Document in the patient record.Documentation is essential after education. To provide continuity of
care within the healthcare team.
Julia Monroe Scenario 3
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