Nursing

12/16/23, 4:44 AM Asti Safar 38-years-old (PN/VN): Attempt review

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Dashboard / Fundamentals / Asti Safar 38-years-old (PN/VN)

12/16/23, 4:44 AM Asti Safar 38-years-old (PN/VN): Attempt review

https://learning.nursethink.com/mod/quiz/review.php?attempt=1910209&cmid=1054 2/4

Started on Saturday, 16 December 2023, 3:25 AM

State Finished

Completed on Saturday, 16 December 2023, 3:44 AM

Time taken 18 mins 52 secs

Grade 100.00 out of 100.00

Question Complete Mark 33.33 out of 33.33

Name: Asti Safar Age: 38 years Provider: M. Patel MD

Code Status: Full Code Admit Wt: 138 lbs (62.6 kg) BMI: 21.9

Allergies: NKA

3/31 0100

Nursing Note: Client arrived with her husband. Client states having back pain, 9/10 on pain scale. The client refuses to make eye contact with staff. She is crying. Husband is at the bedside. The client requested a female nurse for the assessment. She also requested a female provider. She requested to keep her hijab in place but changed into a hospital gown. Guarded when changing positions. Denies any recent injury or trauma.

Before answering this question, review the client’s health information in the EHR. Indicate the findings that are consistent with the client being in pain. Click to highlight the findings.

Nursing Note: Client arrived with her husband. Client states having back pain, 9/10 on pain scale. The client refuses to make eye contact with staff. She is crying. Husband is at the bedside. The client requested a female nurse for the assessment. She also requested a female provider. She requested to keep her hijab in place but changed into a hospital gown. Guarded when changing positions. Denies any recent injury or trauma.

Question Complete Mark 33.33 out of 33.33

Name: Asti Safar Age: 38 years Provider: M. Patel MD

Code Status: Full Code Admit Wt: 138 lbs (62.6 kg) BMI: 21.9

Allergies: NKA

1

Nursing Flowsheets Other

NURSING ASSESSMENT & NOTES

Consider:

1. What nonverbal cues should the nurse watch for with acute pain?

2. What role does culture/religion have in expressing pain?

3. What vital sign changes should the nurse anticipate with acute pain?

2

Nursing Flowsheets Provider Other

NURSING ASSESSMENT & NOTES

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12/16/23, 4:44 AM Asti Safar 38-years-old (PN/VN): Attempt review

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3/31

0100

Nursing Note: Client arrived with her husband. Client states having back pain, 9/10 on pain scale. The client

refuses to make eye contact with staff. She is crying. Husband is at the bedside. The client requested a female

nurse for the assessment. She also requested a female provider. She requested to keep her hijab in place but

changed into a hospital gown. Guarded when changing positions. Denies any recent injury or trauma.

3/31

0700

Pain: Client rating back pain as 4/10.

4/1

0800

Pain: Client rating back pain as 3/10.

Before answering this question, review the client’s health information in the EHR. Complete the sentences using the drop-

down choices.

When prioritizing tasks, the client’s pain level indicates the nurse should

. If the pain increases, the nurse should

.

Question Complete Mark 33.34 out of 33.34

Name: Asti Safar Age: 38 years Provider: M. Patel MD

Code Status: Full Code Admit Wt: 138 lbs (62.6 kg) BMI: 21.9

Allergies: NKA

3/31

0100

Nursing Note: Client arrived with her husband. Client states having back pain, 9/10 on pain scale. The client

refuses to make eye contact with staff. She is crying. Husband is at the bedside. The client requested a female

nurse for the assessment. She also requested a female provider. She requested to keep her hijab in place but

changed into a hospital gown. Guarded when changing positions. Denies any recent injury or trauma.

3/31

0700

Pain: Client rating back pain as 4/10.

4/1 Pain: Client rating back pain as 3/10.

reposition the client

administer pain medication

Consider:

1. What other non-pharmacological pain methods may help the client?

2. What interventions should the nurse consider before giving pain medications?

3. How might you ask this client about methods she has used in the past to deal with pain?

3

Nursing Flowsheets Provider Other

NURSING ASSESSMENT & NOTES

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12/16/23, 4:44 AM Asti Safar 38-years-old (PN/VN): Attempt review

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0800

4/1

1700

Pain: Client rating back pain as 6/10.

Before answering this question, review the client's health information in the EHR. The client’s breakfast tray arrives with toast,

bacon, and eggs. Complete the sentence using the drop-down menus.

The nurse should

because of the client’s

.

not deliver the tray

religion

Consider:

1. What additional guidelines should the nurse be aware of for this client?

2. What food products are not consumed in Islam?

3. What other practices might be impacted by this client’s religious preferences?

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12/16/23, 3:59 AM Colin Rice 43-years-old: Attempt review

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Dashboard / Surgical Care Unit / Colin Rice 43-years-old

12/16/23, 3:59 AM Colin Rice 43-years-old: Attempt review

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Started on Saturday, 16 December 2023, 2:40 AM

State Finished

Completed on Saturday, 16 December 2023, 2:58 AM

Time taken 18 mins 23 secs

Grade 95.83 out of 100.00

Question Complete Mark 29.17 out of 33.34

Name: Colin Rice Age: 43 years Provider: L. Fisher MD

Code Status: Full Code Admit Wt: 233.9 lbs (106.1 kg) BMI: 30.9

Allergies: NKA

Before answering this question, review the client’s health information in the EHR. Identify if each finding is concerning or not concerning to the nurse. Select one answer in each row.

Question Complete Mark 33.33 out of 33.33

Name: Colin Rice Age: 43 years Provider: L. Fisher MD

Code Status: Full Code Admit Wt: 233.9 lbs (106.1 kg) BMI: 30.9

Allergies: NKA

1

Nursing Flowsheets Provider Lab & Diagnostics

NURSING ASSESSMENT & NOTES

3/18 1625

Nursing Note: Received from OR, transferred by circulating RN and anesthesiologists. Blood pressure cuff, SpO monitor, and ECG monitor were applied. The client is drowsy. Call light within reach. Siderails up. Abdominal dressing clean, dry and intact. NG tube intact and draining scant amounts of green-yellow drainage.

2

Concerning Not concerning

Blood pressure

NG tube drainage

SpO2

Heart rate

Dressing

Pain rating

Drowsiness

History of Crohn’s disease

Consider:

1. What pathophysiological changes occur in Crohn's Disease? Why are clients with Crohn's subject to bowel obstruction and surgery?

2. What are the nursing priorities in the immediate post-anesthesia period?

3. What risks or complications are associated with the post-anestheia period?

2

Nursing Flowsheets Provider Lab & Diagnostics MAR

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12/16/23, 3:59 AM Colin Rice 43-years-old: Attempt review

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3/18 1625

Nursing Note: Received from OR, transferred by circulating RN and anesthesiologists. Blood pressure cuff, SpO monitor, and ECG monitor were applied. The client is drowsy. Call light within reach. Siderails up. Abdominal dressing clean, dry and intact. NG tube intact and draining scant amounts of green-yellow drainage.

3/18 1640

Nursing Note: Client alert and oriented x 4. PCA initiated. Client educated on PCA. The client was educated on the nasogastric tube with verbal understanding. Client rating pain 6/10.

3/18 1645

Nursing Note: NG connected to low intermittent suction and NPO per change in provider’s order. Client rating pain 8/10.

3/18 1705

Nursing Note: Client pressing PCA bolus button about every 10 minutes. Client rating pain 8/10.

Before answering this question, review the client’s health information in the EHR. The nurse is educating the client about the patient-controlled analgesia. Indicate the client statements that would require additional teaching. Select the three (3) that apply.

Question Complete Mark 33.33 out of 33.33

Name: Colin Rice Age: 43 years Provider: L. Fisher MD

Code Status: Full Code Admit Wt: 233.9 lbs (106.1 kg) BMI: 30.9

Allergies: NKA

NURSING ASSESSMENT & NOTES

2

“I will push the button when I want medicine for my pain.”

“The dose of medicine is calculated, so it is safe.”

“I need to only push the button when I can’t stand the pain anymore.”

“I can only have the PCA in the PACU, not when I get to the unit.”

“I don’t need to push the button, it will give me medicine anyway.”

“The machine has a lock-out mechanism, so I can’t take too much medicine.”

“I will use less medicine by my being in control of the medicine myself.”

“I will take good deep breaths if my pain is well managed.”

Consider:

1. Teach a peer about the use of patient-controlled analgesia.

2. Create a teaching plan for a client who has a nasogastric tube. How would the teaching be adapted because the client had the nasogastric tube in the emergency department?

3. Compare the vital signs. What trends do you notice in that data?

3

Nursing Flowsheets Provider Lab & Diagnostics MAR

NURSING ASSESSMENT & NOTES

3/18 Nursing Note: Received from OR, transferred by circulating RN and anesthesiologists. Blood pressure cuff, SpO monitor, and ECG2

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12/16/23, 3:59 AM Colin Rice 43-years-old: Attempt review

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Before answering this question, review the client’s health information in the EHR. Identify if each finding indicates if pain management is effective or ineffective. Select one answer in each row.

1625 g y g g p p

monitor were applied. The client is drowsy. Call light within reach. Siderails up. Abdominal dressing clean, dry and intact. NG tube intact and draining scant amounts of green-yellow drainage.

2

3/18 1640

Nursing Note: Client alert and oriented x 4. PCA initiated. Client educated on PCA. The client was educated on the nasogastric tube with verbal understanding. Client rating pain 6/10.

3/18 1645

Nursing Note: NG connected to low intermittent suction and NPO per change in provider’s order. Client rating pain 8/10.

3/18 1705

Nursing Note: Client pressing PCA bolus button about every 10 minutes. Client rating pain 8/10.

3/18 1800

Nursing Note: Dr. Fisher called regarding the client’s pain unresolved with PCA. Prescriptions received. Basal rate added to PCA & ketorolac administered.

Effective Ineffective

Blood Pressure

SpO2

Heart rate

Temperature

Pain rating

Respiratory rate

Consider:

1. Explain the pathophysiology of pain and its impact on vital signs or other functions.

2. What other signs and symptoms are used to assess pain and the effectiveness of interventions?

3. What could be the reasons for the client's desaturation at 1750?

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