Nursing homework

Nursing Skills & Reasoning

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Blood Transfusion

1. Which findings from the present problem are most important and noticed by the nurse as clinically significant?

Most Important Findings Clinical Significance

Procedural Safety Principles: Blood Administration
2. What will you do if you have not performed blood administration in the clinical setting?

3. If the nurse was going to administer another unit of packed red blood cells (PRBC), what supplies does the nurse

need to gather?

4. Review and summarize essential steps and knowledge the nurse will apply to administer the remainder of this

transfusion safely.

5. What will the nurse communicate to educate the patient or family about the need for this procedure and what to

expect?

Nursing Skills & Reasoning

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form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN

Evaluation

6. You collect the following assessment data. Make a clinical judgment for each finding by placing an “x” in the

appropriate column if the finding is expected or unexpected.

Assessment Finding Expected Unexpected

T: 98.2 F/36.8 C (oral)

P: 108 (regular)

R: 25 (regular)

BP: 128/83

O2 sat: 88% RA

Appears anxious

Breathing rapidly

Skin is cool and clammy

7. Is the overall status of the patient:

a. Improved

b. Declined

c. No change

8. Complete the table below for each home medication.

Medication Pharm. Class Mechanism of Action Expected Outcome

Metoprolol

Lisinopril

Furosemide

Ferrous gluconate

Potassium chloride

9. Which home medication(s) that were not taken would have the greatest impact on his current status?

Medication Rationale

Nursing Skills & Reasoning

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form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN

10. Calculate the patient’s total intake and output, then interpret the significance of your findings.

Intake and Output Clinical Significance

11. What clinical data is most important and must be recognized as clinically significant by the nurse?

Most Important Data Clinical Significance

12. To interpret the clinical data collected, list at least two possible problems for this patient. Which problem is the

priority?

Possible Problems Priority Problem Pathophysiology of Priority Problem

13. After evaluating the patient, identify the current nursing priority and which action(s) the nurse should take. List

interventions by priority and the expected outcome.

Nursing Priority

Priority Intervention(s) Rationale Expected Outcome

Nursing Skills & Reasoning

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form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN

14. Recognizing a potential problem, you use Identify-Situation-Background-Assessment-Recommendation (ISBAR)

to update the provider. Summarize what you would communicate for an ISBAR report.

I identify Specify who you are/where you work.

• Yourself: name/position/location

• Patient: name/age/gender

S situation
What is the problem/reason for contact?

Concise summary of primary problem:

B background
If urgent, state concern. Provide concise/relevant history

• Primary problem/diagnosis:

• Day of admission/post-op day #:

• Relevant past medical history:

• Relevant treatments/interventions:

A assessment
Assessment of the situation using the most important clinical data.

State your concern by communicating

concerning clinical data:

• Vital signs

• Nursing assessment

• Lab/diagnostic results

Trend of most important clinical data

(stable-increasing/decreasing):

R recommendation
Request specific advice/interventions. Clarify expectations.

• Nurse suggestions to advance the plan

of care:

• What do you recommend?

• Repeat and state back new

orders/confirm plan of care:

Nursing Skills & Reasoning

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form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN

15. Identify the rationale for each provider order and its expected outcome.

Provider Orders Rationale Expected Outcome

Furosemide 40 mg IV push

Discontinue blood

transfusion

Apply oxygen to maintain

oxygen saturation >92%

Dosage Calculation: Furosemide 40 mg IV push
Medication

Time frame to

Administer

Show Work Volume to Administer

16. Which findings are expected if the nursing and medical intervention(s) were effective?

Expected Findings Rationale

Nursing Skills & Reasoning

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form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN

17. The nurse has implemented the medical and nursing plan of care. One hour later, you collect the following

assessment data below.

For each finding, make a clinical judgment by placing an “x” in the appropriate column if the patient’s

condition has improved, has not changed, or has declined.

Assessment Finding Improved No Change Declined

Urine output: 750 mL

HR: 89/minute

RR: 18/minute non-labored

BP: 124/80

O2 sat: 96% room air

Crackles persist in bases but are not as pronounced

Resting comfortably appears less anxious

18. Is the overall status of the patient:

a. Improved

b. No change

c. Declined

Documentation
Write a concise nurse’s note to document what was most important in the medical record.

Nurse Reflection
To strengthen your clinical judgment skills, reflect on your knowledge and the decisions made caring for this patient by

answering the reflection questions below.

Reflection Question Nurse Reflection

As you worked through this

simulation, how did it make you

feel?

What did you already know and do

well on this simulation?

What areas do you need to

develop/improve?

What did you learn? How will you

apply what was learned to improve

patient care?

1. Most Important Findings:
2. Clinical Significance:
3. 2:
4. need to gather:
5. transfusion safely:
6. expect:
7. Assessment Finding:
8. ExpectedT 982 F368 C oral:
9. UnexpectedT 982 F368 C oral:
10. ExpectedP 108 regular:
11. UnexpectedP 108 regular:
12. ExpectedR 25 regular:
13. UnexpectedR 25 regular:
14. ExpectedBP 12883:
15. UnexpectedBP 12883:
16. ExpectedO2 sat 88 RA:
17. UnexpectedO2 sat 88 RA:
18. ExpectedAppears anxious:
19. UnexpectedAppears anxious:
20. ExpectedBreathing rapidly:
21. UnexpectedBreathing rapidly:
22. ExpectedSkin is cool and clammy:
23. UnexpectedSkin is cool and clammy:
24. Medication:
25. Pharm ClassMetoprolol:
26. Mechanism of ActionMetoprolol:
27. Expected OutcomeMetoprolol:
28. Pharm ClassLisinopril:
29. Mechanism of ActionLisinopril:
30. Expected OutcomeLisinopril:
31. Pharm ClassFurosemide:
32. Mechanism of ActionFurosemide:
33. Expected OutcomeFurosemide:
34. Pharm ClassFerrous gluconate:
35. Mechanism of ActionFerrous gluconate:
36. Expected OutcomeFerrous gluconate:
37. Pharm ClassPotassium chloride:
38. Mechanism of ActionPotassium chloride:
39. Expected OutcomePotassium chloride:
40. MedicationRow1:
41. RationaleRow1:
42. Intake and OutputRow1:
43. Clinical SignificanceRow1:
44. Most Important DataRow1:
45. Clinical SignificanceRow1_2:
46. Possible ProblemsRow1:
47. Priority ProblemRow1:
48. Pathophysiology of Priority ProblemRow1:
49. Nursing Priority:
50. Priority InterventionsRow1:
51. RationaleRow1_2:
52. Expected OutcomeRow1:
53. I identify:
54. Specify who you arewhere you workYourself namepositionlocation Patient nameagegender:
55. S situation:
56. What is the problemreason for contactConcise summary of primary problem:
57. B background:
58. If urgent state concern Provide conciserelevant historyPrimary problemdiagnosis Day of admissionpostop day Relevant past medical history Relevant treatmentsinterventions:
59. A assessment:
60. Assessment of the situation using the most important clinical dataState your concern by communicating concerning clinical data Vital signs Nursing assessment Labdiagnostic results Trend of most important clinical data stableincreasingdecreasing:
61. R recommendation:
62. Request specific adviceinterventions Clarify expectationsNurse suggestions to advance the plan of care What do you recommend Repeat and state back new ordersconfirm plan of care:
63. Provider Orders:
64. RationaleFurosemide 40 mg IV push Discontinue blood transfusion Apply oxygen to maintain oxygen saturation 92:
65. Expected OutcomeFurosemide 40 mg IV push Discontinue blood transfusion Apply oxygen to maintain oxygen saturation 92:
66. Administer:
67. Show Work:
68. Expected FindingsRow1:
69. RationaleRow1_3:
70. Assessment Finding_2:
71. ImprovedUrine output 750 mL:
72. No ChangeUrine output 750 mL:
73. DeclinedUrine output 750 mL:
74. ImprovedHR 89minute:
75. No ChangeHR 89minute:
76. DeclinedHR 89minute:
77. ImprovedRR 18minute nonlabored:
78. No ChangeRR 18minute nonlabored:
79. DeclinedRR 18minute nonlabored:
80. ImprovedBP 12480:
81. No ChangeBP 12480:
82. DeclinedBP 12480:
83. ImprovedO2 sat 96 room air:
84. No ChangeO2 sat 96 room air:
85. DeclinedO2 sat 96 room air:
86. ImprovedCrackles persist in bases but are not as pronounced:
87. No ChangeCrackles persist in bases but are not as pronounced:
88. DeclinedCrackles persist in bases but are not as pronounced:
89. ImprovedResting comfortably appears less anxious:
90. No ChangeResting comfortably appears less anxious:
91. DeclinedResting comfortably appears less anxious:
92. Write a concise nurses note to document what was most important in the medical record:
93. Reflection Question:
94. Nurse Reflection:
95. Nurse ReflectionWhat did you already know and do well on this simulation:
96. Nurse ReflectionWhat areas do you need to developimprove:
97. Nurse ReflectionWhat did you learn How will you apply what was learned to improve patient care:
98. Text1: