Med Surg Swift River_2020 TEST BANK | NURS 320 Med_Surg_Swift_River_Graded A

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NURS 320 Med_Surg_Swift_River **New Patients from 2020, Post- Covid-19 Update:** **Charlie Raymond , John Duncan, Carlos Mancia, kenny barrett, Tim Jones, Julia Monroe, Donald Lyles, John Wiggins,... Richard Dominec, Preston Wright, Tom Richardson, Joyce Workman, Karen Cole, Jose Martinez, Mary Barkley Charlie Raymond (for older swift river patients see other pdf files loaded at the bottom of this file) Preston Wright Room 301 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. You responded correctly to 6 out of 6 evaluations: Category Your respons e Explanation Education al Needs Increased acuity Mr. Wright needs further understanding of why it is important to stay off of the increased pressure areas. Fall Risk Increased acuity Due to Mr. Wright’s age and diagnosis, as well as optional pain medications, he is at risk for falling. Health change Increased acuity Due to the compromise in Mr. Wright’s skin condition, he is more susceptible to infection and further injury. Neurologi cal Normal acuity He is awake, alert, and cooperative. Pain level Increased acuity Normal, rationale: Patient states the pain has subsided Psycholog ical Needs Normal acuity Mr. Wright does not present with any psychological needs currently. You correctly diagnosed 10 out of 12 options: Physiological Description Your Respon se Explanation Acute Pain TRUE Related to tissue destruction and exposure of nerves. Altered Body Image TRUE Related to skin healing misconfiguration. Constipation FALSE Patient does not complain of constipation at this time. Impaired Communication FALSE no evidence of impaired communication. Impaired Physical Mobility TRUE Related to wound location. Impaired Tissue Integrity TRUE Due to altered circulation and altered physical mobility. Ineffective Airway Clearance FALSE Patient has no evidence of breathing problems. Ineffective Breathing Pattern FALSE Patient has no evidence of breathing problems. Risk for Imbalanced Nutrition FALSE Mr. Wright needs increased protein for healing of pressure injuries. Safety Description Your Respon se Explanation Isolation Precaution FALSE Patient is not in isolation. Risk for Infection TRUE Related to physical immobility, shearing forces, precautions at this time. Risk for Injury related to Falls FALSE Scenario states patient is an increased fall risk. Preston Wright Scenario 1 Mr. Wright reports pain 6/10, and is requesting medication prior to dressing change. You correctly ordered 5 out of 5 actions: Yo Co ur rre or ct de ord r er Step Explanation 1 1 Assess current pain level. Assessment is always the first step of the nursing process. 2 2 Assess documented pain level and intervention by previous nurses. Review nurses notes for previous pain assessment, intervention, and effectiveness/response for nurses action. 3 3 Review medication orders for pain. Reviewing orders to ensure proper medication is administered. 4 4 Prepare and administer appropriate pain medication. Prepare proper medication as ordered. Administer pain medication – Once medication is prepared, administer as ordered. 5 5 Reassess pain level. After proper medication is administered, reassess pain level in 30 minutes for effectiveness. Preston Wright Scenario 2 Mr. Wright insists that he watches TV from the High Fowler’s position. The nurse repositioned the patient to the left side to decrease pressure on the sacrum and right heel. Sacrum pressure injury demonstrates underlying bone exposure wound measures 4 cm x 6 cm x 3 cm depth with tunneling noted on the right side. The right heel demonstrates a blister 2 cm x 1 cm with clear fluid noted. You correctly ordered 5 out of 5 actions: Yo Co ur rre or ct de ord r er Step Explanation 1 1 Assess Mr. Wright’s willingness to learn. Assessment is always the first step in the nursing process. If Mr. Wright is unable/unwilling to learn currently, there is no need to move forward. 2 2 Eliminate as many distractions as possible. Elimination distractions promotes a beneficial learning environment. 3 3 Explain rationales for pressure relief to injured areas. Educates Mr. Wright about nursing interventions to allow for wound healing. 4 4 Assess understandin g through teach back. Ensures validation of understanding by Mr. Wright. 5 5 Document responses. Documentation is necessary to validate education was provided and understood. Preston Wright Scenario 3 The Healthcare Provider is requesting an update on sacral wound healing. You correctly ordered 5 out of 5 actions: Y Co o rre ur ct or or d de er r Step Explanation 1 1 Remove old dressing with clean gloves daily. Removal of old dressing is a clean procedure because it is already contaminated. 2 2 Assess the injury for presence of necrotic tissue and amount of exudate. Daily assessment of wounds is needed when the patient is in an acute-care setting. 3 3 Assess and document the condition of the skin surrounding the pressure injury in terms of color, temperature, texture, and moisture. Pressure injuries may have more tissue destruction than what is first seen upon inspection. Inspect undermine areas for gradual filling with healthy granulation tissue. - - - - Continued [Show More]

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