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Kenny Barrett Room 301
Kenny Barrett, 64 years old, was admitted for observation of initial
administering of BP his treatment with blood pressure of 220/124 after
visiting his doctor for a routine physical. ECG was unremarkable. No past
history of HTN. Past medical history includes hyperlipidemia, current
elevated triglycerides, and a history of 1 pack a day smoker for the past 20
years. Vital signs are Temp 98.9F, BP 178/90, P 88, RR 18 SaO2 95% on
Room air. IV with NS @ 125 mL/ hr. Patient has been complaining of a
headache and dizziness. He is a patient of Dr. Adams.
You responded correctly to 4 out of 6 evaluations:
Category
Your
response
Explanation
Perfusion (yes)
Incorrect
acuity
Patient is at risk because of his BP and
pulse
Gas exchange (no)
Incorrect
acuity
No indication at this time
Interpersonal violence
(no)
Incorrect
acuity
No indication at this time
Addiction (yes)
Incorrect
acuity
History of 1 pack a day smoker for the
past 20 years
Cognition (no)
Incorrect
acuity
Patient is AAO x 4
Sexuality (no)
Incorrect
acuity
No evidence of abnormal sexual history
Scenario 1
When reviewing your patients’ vital signs, taken by the UAP, you notice
Kenny has a blood pressure of 190/110 and a pulse of 105. What actions by
the nurse are appropriate?
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You correctly selected 3 out of 5 actions:
Your
Correc
t
Answe Answe Stat
r r us Label Explanation
No Yes Reassess blood
pressure and
pulse
No Yes Educate UAP
regarding
notification of
abnormal range
of vital signs
No No Administer
second dose of
BP medicine
No No Ask patient to
remain in bed
until further
evaluated
No No Provide bolus of
IV fluids
All vital signs taken
that are abnormal by
UAP should be
confirmed by licensed
nurse
Abnormal values
require further
assessment by
licensed nurse and
need to be reported by
the UAP immediately
There is no order for BP
medicine at this point
There is no order for
patient to be on bed
rest
A bolus would not help
lower patient’s BP
Scenario 2
When re-taking the patient’s BP, you get a reading of 184/108 and a pulse of
102. Report finding to Dr. Adams using SBAR. What should be included in the
“S”?
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Kenny Barrett Room 301Kenny Barrett, 64 years old, was admitted for observation of initialadministering of BP his treatment with blood pressure of 220/124 aftervisiting his doctor for a routine physical. ECG was unremarkable. No pasthistory of HTN. Past medical history includes hyperlipidemia, currentelevated triglycerides, and a history of 1 pack a day smoker for the past 20years. Vital signs are Temp 98.9F, BP 178/90, P 88, RR 18 SaO2 95% onRoom air. IV with NS @ 125 mL/ hr. Patient has been complaining of aheadache and dizziness. He is a patient of Dr. Adams.You responded correctly to 4 out of 6 evaluations:CategoryYourresponseIncorrectacuityIncorrectGas exchange (no)acuityInterpersonal violence Incorrect(no)acuityIncorrectAddiction (yes)acuityIncorrectCognition (no)acuityIncorrectSexuality (no)acuityPerfusion (yes)ExplanationPatient is at risk because of his BP andpulseNo indication at this timeNo indication at this timeHistory of 1 pack a day smoker for thepast 20 yearsPatient is AAO x 4No evidence of abnormal sexual historyScenario 1When reviewing your patients’ vital signs, taken by the UAP, you noticeKenny has a blood pressure of 190/110 and a pulse of 105. What actions bythe nurse are appropriate?You correctly selected 3 out of 5 actions:CorrectYourAnswe Answe StatrrusLabelNoYesReassess bloodpressure andpulseNoYesNoNoNoNoNoNoExplanationAll vital signs takenthat are abnormal byUAP s ...
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