SWIFT RIVER MEDICAL-SURGICAL:

EXAM, 2025/2026 WITH

CORRECT/ACCURATE ANSWERS
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Sarah Getts Scenario 1
Sarah GettsMs. Getts is requesting water
to drink. Her pitcher has already been
filled three times this shift.
1- Wash and glove hands
2- Full assessment
3- Monitor and evaluate fluid intake
4- Educate patient
5- Document results
Sarah Getts Scenario 2
Sarah GettsThree hours later, Ms. Getts is
unsteady when standing by her bedside.
1- Wash and glove hands
2- Full assessment
3- Apply fall risk bracelet
4- Document results
Sarah Getts Scenario 3
Sarah GettsYou observe Ms. Getts being
assisted by another nurse who is being
blatantly rude and disrespectful to her.
1- Offer assistance
2- Remain with patient
3- Therapeutic Communication
4- Notify lead nurse
5- Document results
Sarah Getts Scenario 4
Sarah GettsMs. Getts is now complaining
of sudden sharp, substernal chest pain,
very short of breath and is profusely
diaphoretic.
1- Visual assess
2- Call rapid response
3- Apply oxygen
4- Establish second IV
5- Remain with patient
Sarah Getts Scenario 5
Sarah GettsMs. Getts is being transferred
as an emergency to Critical Care. Your
responsibilities are:
1- Give verbal report
2- Escort patient
3- Notify family
4- Document results
Paul Greer
Paul Greer is a 57 y/o who has been
admitted for a radical prostatectomy. He
was recently diagnosed with stage III
prostate cancer. His original lymph node
biopsy was negative. He has a history of
hypertension and is not compliant with
medication. Until the recent diagnosis of
cancer, the patient had only seen a
physician once in the last ten years. He
has a 20-year one pack history of
smoking. However, he quit three years
ago when he remarried; he and his wife
have a nine-month-old baby. His difficulty
voiding finally motivated him to seek
care.
Alteration in comfort
Knowledge deficit
Potential for ineffective sexuality patterns
Sarah Getts
Sarah Getts 77 yr-old, Dx- Chronic Renal
Failure, admitted with hyperkalemia (5.9,
Eq/L)/hyponatremia (128mEq/L). No
known allergies (NKA). Vital signs -Temp
98.8, BP 102/76, P 102- irregular, RR 22,
SaO2 90%, cardiovascular on telemetry
with Sinus irregular rhythm. Disoriented
to time and place, speech slurred. Pupils
PERRLA, eyes clear. 20 ga. Hep-Lock in
right forearm, skin warm and dry,
generalized weakness with recent weight
loss. 50% intake. High fall risk. Renal diet.
Family in room with patient very
concerned. Dr. Brown
Electrolyte Imbalance
Ineffectual renal perfusion, risk for
Potential for imbalanced fluid volume
Acute Confusion
Potential for falls
Failure to Thrive
Calvin Umbyuma Scenario 1
Calvin UmbyumaThe nurse is doing the
admission and has trouble pronouncing
the patient's name. He tells the nurse to
call him U. Mr. U starts coughing, his
sputum is greenish-yellow with blood
tinge. He tells the nurse that it is very
painful to cough. The nurse asks him if he
has night sweats, and he says yes, for the
past 4 weeks. Mr. U has traveled back to
Kenya twice this year as his mother has
been very ill. He tried to convince her to
seek medical attention, but his family is
very traditional and believes in other
methods of treatment. Mr. U admitted he
also has been using traditional methods
to treat his HIV. The nurse has an order
for an IV with antibotics q6hr., blood
cultures x2, and Tylenol for pain and
fever.
1- Place on respiratory isolation
2- Ask Mr. U about the traditional
methods he is currently receiving
3- Obtain blood cultures x2
4- Start IV and antibotics
5-Collect sputum culture and remind the
provider that a sputum culture order is
needed. This will allow check sputum for
acid-fast bacilli
Calvin Umbyuma Scenario 2
Calvin UmbyumaMr. U calls the nurse to
his room complaining of severe pain when
he coughs, and his shortness of breath
has become worse. A visitor is in the
room without a mask and has delivered
Mr. U's medication from home to include
his traditional herbal remedies. Mr. U
admits that he was trying to take his
medicine when he experienced an
episode of uncontrollable cough. Upon
review of Mr. U's previous chest X-ray,
you have identified an abnormal chest X-
ray showing a patchy shadowing in the
right upper lobe.
1- Wash hands, don PPE
2- Explain to the visitor that a mask must
be worn, and they need to wash their
hands
3- Respiratory assessment and assess
vital signs
4- Ask Mr. U for his medication and
explain to Mr. U why he can't take his
other medication while admitted to the
hospital
5- Place signage on door and above bed
reminder to wear a mask and wash hands
Calvin Umbyuma Scenario 3
Calvin UmbyumaMr. U does not want to
give up his traditional herbal medications.
He tells the nurse that his father died in
the best hospital in Kenya receiving the
newest treatment. The nurse inquires as
to the father's illness and Mr. U tells the
nurse that he believes it was
Tuberculosis. He does not know what his
mother is suffering from as she refuses to
seek modern treatment. Mr. U is also
concerned about his wife as she has been
having difficulty with her Visa and is still
trying to come back to the US
1- Ask patient what he knows about
Tuberculosis
2- Ask patient what his mother's
symptoms are
3- Educate patient to the signs/symptoms
of Tuberculosis
4- Evaluate effectiveness of patient
education
5- Report findings to the HCP, notify
infection control and social services
Calvin Umbyuma Scenario 4
Calvin UmbyumaMr. U test positive for TB
and new medications are ordered
(kanamycin and moxifloxacin). His T-cell
count is 160 with CD4 cell at 16%. A
consult has been ordered for an infectious
disease provider to manage his TB and
HIV. The nurse is very concerned that this
his TB is a resistant strain as this can be
carried with HIV infected patients. The
nurse is also concerned about the social
contacts that Mr. U has had in the recent
past including his visitor that was not
wearing a mask. The nurse has received
multiple diagnostic orders that need to be
done ASAP. Current vital signs are: 100.6
F, 38.1 C, R:22, P:86, PaO2: 91% Prioritize
the following: Blood Gases,
Bronchoscopy, Western blot and Elisa
test, Chest x-ray, provide patient teaching
about diagnostic testing,
1- Patient teaching about diagnostic
testing (Bronchoscopy)
2- Contact Respiratory therapy to obtain
ABG's
3- Chest x-ray
4- Western blot and Elisa test
5- Bronchoscopy
Calvin Umbyuma Scenario 5
Calvin UmbyumaMr. U's condition
continues to deteriorate, and his tests
come back positive for TB. The nurse is
informed by the CNA that his pulse-
oximetry is 89 on room air and he looks
very dusky. The CNA also tells the nurse
that while they were taking his VS, he
coughed up bloody sputum.
1- Elevate head of bed
2- Initiate O2 at 4L nasal canula
3- Reassess vital Signs
4- Reevaluate amount of blood lost by
coughing
5- Contact HCP and nursing supervisor
Calvin Umbyuma | Room 304
Patient Overview
Calvin_Umbsya.jpgCalvin UmbyumaMr.
Umbyuma is a 42 y/o male who has been
admitted for complaints of shortness of
breath with pleuritic chest pain. He was
diagnosed with HIV positive antibodies
over a year ago. He has recently been
traveling back to his home country of
Kenya to visit his sick mother. He
received traditional medical treatment at
his village. His temp is 100.9 F, 38.3 C, R
22, P92, BP 152/89 PaO2 91%.
Inflammatory markers - Erythrocyte
Sedimentation Rate (ESR) and C-Reactive
Protein (CRP) are elevated at 78.9 mm/h
and 67.2 mg/L. He has been placed in a
room at the end of the hall.
Educational Needs- Increased
Fall Risk- Normal
Health Change- Increased
Neurological- Normal
Pain Level- Increased
Psychological Needs- Normal
Calvin Umbyuma
Calvin Umbyuma Mr. Umbyuma is a 42
y/o male who has been admitted for
complaints of shortness of breath with
pleuritic chest pain. He was diagnosed
with HIV positive antibodies over a year
ago. He has recently been traveling back
to his home country of Kenya to visit his
sick mother. He received traditional
medical treatment at his village. His temp
is 100.9 F, 38.3 C, R 22, P92, BP 152/89
PaO2 91%. Inflammatory markers -
Erythrocyte Sedimentation Rate (ESR)
and C-Reactive Protein (CRP) are elevated
at 78.9 mm/h and 67.2 mg/L. He has been
placed in a room at the end of the hall.
Acute discomfort
Knowledge deficit

Wight Goodman | Room 301

Patient Overview
wight_goodman.jpgWight
GoodmanPatient was admitted to the
floor last night from the ER for an orbital
fracture. He was hit in the left eye by a
softball yesterday. Apparently, he was
pitching, and the batter hit a line drive
hitting him in the right side of the face.
They applied some ice to his face, and he
decided to go to the post game keg party
instead of coming to the ER. The patient
stated that there was significant swelling,
but his vision was fine, and the pain was
controlled with beer and 800mg of Motrin.
He was unable to sleep later in the
evening as the pain became worse, and
his vision became more impaired. Patient
states, "I'm afraid I will be permanently
scarred"! The Maxillofacial surgeon was
consulted, and they will see him this
morning. They were not concerned as his
intraocular pressure was normal in the
ER. There is significant edema and
discoloration to the left side of his face,
and his left eye is almost completely
swollen shut. His visual acuity is
diminished, and the whites of his eyes are
hemorrhaged. His pain has been well
controlled with IV morphine 4 mg, q3
hours. He has a 20g SL to his right hand,
that was started in the ER. He has no
other health concerns. He's being
admitted for pain control, close
observation of his intralocular pressure,
and head injury.
Educational Needs- Increased
Fall Risk- Increased
Health Change- Increased
Neurological- Increased
Pain Level- Increased
Psychological Needs- Increased
Wight Goodman
Wight Goodman Patient was admitted to
the floor last night from the ER for an
orbital fracture. He was hit in the left eye
by a softball yesterday. Apparently, he
was pitching, and the batter hit a line
drive hitting him in the right side of the
face. They applied some ice to his face,
and he decided to go to the post game
keg party instead of coming to the ER.
The patient stated that there was
significant swelling, but his vision was
fine, and the pain was controlled with
beer and 800mg of Motrin. He was unable
to sleep later in the evening as the pain
became worse, and his vision became
more impaired. Patient states, "I'm afraid
I will be permanently scarred"! The
Maxillofacial surgeon was consulted, and
they will see him this morning. They were
not concerned as his intraocular pressure
was normal in the ER. There is significant
edema and discoloration to the left side
of his face, and his left eye is almost
completely swollen shut. His visual acuity
is diminished, and the whites of his eyes
are hemorrhaged. His pain has been well
controlled with IV morphine 4 mg, q3
hours. He has a 20g SL to his right hand,
that was started in the ER. He has no
other health concerns. He's being
admitted for pain control, close
observation of his intralocular pressure,
and head injury.
Acute discomfort
Alteration in comfort
Potential for bleeding
Knowledge deficit
Potential for infection
Wight Goodman Scenario 1
Wight GoodmanMr. Goodman has been
scheduled for surgery to repair a
supraorbital rim fracture, but he is very
concerned about any scaring that may
affect his appearance. He is alert and
oriented and has signed the surgical
consent. The nurse notices a small
amount of blood coming from the
patient's nose. He does not remember his
nose bleeding initially or in the ER. VS
BP140/82 P74 R 20 T 98.7 F, 37.1 C.
1- Wash hands and assess
2- Complete Neurological assessment
3- Check the blood from his nose for CSF
4- Pre-op education
5- Ask Surgeon to discuss with patient the
potential facial scarring
Wight Goodman Scenario 2
Wight GoodmanThe blood from the nose
was positive for CSF. An MRI is ordered,
and reveals a small Orbital roof fracture.
The neurosurgeon is consulted. The
maxillofacial surgeon will repair the
suborbital rim fracture first, and the
neurosurgeon will monitor the patient
postoperatively as well as be available to
assist if the orbital roof fracture becomes
unstable. IV antibiotics are ordered to be
administered ASAP. The patient will need
to sign another surgical consent for
potential neurosurgery. The surgeon also
orders Neuro checks q2 hours, his
Glasgow Coma Score is 15.
1- Complete Neurological assessment
2- Educate patient of plan of care
3- Evaluate patients understanding of
care
4- Administer IV antibiotics
5- Sign additional surgical consent
Wight Goodman Scenario 3
Mr. Goodman is first day post-op from his
suborbital rim fracture repair, and his
orbital edema has been greatly reduced.
His CSF with rhinorrhea has subsided. The
neurosurgeon has decided to continue to
observe his recovery, instead of surgical
intervention to repair the orbital roof
fracture. The patients VS are stable, and
he is afebrile. Patient does not have
medical insurance, so he is wanting to
leave today. The patient is emotionally
distraught, and angry as face appears to
have drooping of his eyelid and his visual
acuities have not improved. While the
swelling has decreased there is still
periorbital edema (Ptosis).
1- Complete Neurological Assessment
2- Educate patient and family of necessity
for q2 hour neuro checks and visual
acuities
3- Inform Healthcare Provider that patient
is medically indigent, and wanting to go
home today
4- Contact social services to discuss
options for payment
5- Extensive discharge planning and
education
Wight Goodman Scenario 4
Wight GoodmanThe resident has been
rounding on Mr. Goodman and is
preparing his discharge. Mr. Goodman is
still very upset about his appearance. He
is also complaining of nasal congestion
and insists on trying to blow his nose. The
nurse informs the resident that his visual
acuities are worse, patient's eyelid is
drooping, and his left-eye (OS) pain is
increasing . The resident tells the nurse
that is a common complication with this
type of injury, and they will see him in the
clinic for a follow-up.
1- Repeat Neurological assessment and
contrast your latest findings
2- Reemphasize to patient that he cannot
blow his nose
3- Approach Resident again, and explain
that you feel his condition is worsening
4- Contact Nursing Supervisor of
disagreement of patients readiness for
discharge
5- Document
Wight Goodman Scenario 5
Wight GoodmanThe attending
maxillofacial surgeon comes to see the
patient before his discharge at the
nurse's insistence. He agrees that the
visual acuity is a concern and consults an
ophthalmologist. It is discovered that Mr.
Goodman has increased intraocular
pressure, and it may be a result of
suborbital edema which will require STAT
surgical decompression to preserve his
sight. Mr. Goodman is irate, starts yelling
at the nurse, and accidentally pulls out
his IV. He believes they have caused him
permanent disfigurement and now
blindness. The nurse must restart his IV
and obtain another surgical consent.
1- Assure patient that surgery is
necessary to preserve his sight, and that
this should not be permanent
2- Take vital signs and position patient 30
degrees upright
3- Restart patients IV
4- Obtain surgical consent
5- Remain with patient
John Davis | Room 304
Patient Overview
John_Davis.jpgJohn Davisis a 54 y/o male
admitted for surgical resection and biopsy
of multiple lesions on his back and
shoulders. The patient is fair skinned with
multiple moles on his shoulders and
anterior and posterior torso. The patient
is high risk for basal cell carcinoma and
has had mole - mapping. Mr. Davis is very
thin and reports an 8 lbs. weight loss over
the last four months. He owns a
landscape business, works outside, he
also enjoys being out on his boat. He had
a basil cell carcinoma removed from his
forehead four years ago (Mohs
micrographic surgery) which has left a
large scar. Mr. Davis is concerned about
potential scars from these lesions. He
denies any other health issues. The
patient does not smoke, but drinks 2
beers after work daily and more on the
weekends. VS BP 150/89, P 62, R 14, T
98.2.
Educational Needs- Increased
Fall Risk- Normal
Health Change- Increased
Neurological- Normal
Pain Level- Normal
Psychological Needs- Normal
Hannah Knox | Room 302
Patient Overview
hannah_knox.jpgHannah Knoxis a 62 y/o
patient who has been receiving hospice
care for metastatic lung cancer. She
continued to smoke until recently. The
plan was for her to die at home, but her
daughter couldn't handle having her in
her home after 2 weeks of hospice care.
The daughter was complaining that her
mother was in an extreme amount of
pain, and her family could not cope. Ms.
Knox is frail, weak, and apprehensive
about her care. Her lung sounds are
diminished in her lower lobes bilaterally,
and she has crackles in her upper lobes.
She is on 4L O2 nasal canula. She has a
pic-line in her right arm. Vital signs BP:
98/52, P: 92, R: 30, SpO2: 91, T:100.2F,
37.8 C
Educational Needs- Increased
Fall Risk- Increased
Health Change- Increased
Neurological- Normal
Pain Level- Increased
Psychological Needs- Increased
Hannah Knox Scenario 1
Hannah KnoxWhile assessing Ms. Knox,
the nurse is unable to flush the pic line.
She has been diagnosed with pneumonia,
and antibiotics have been ordered. IV to
include a morphine PCA for pain. A foley
catheter is ordered to manage
incontinence. Ms. Knox seems upset with
her daughter for bringing her to the
hospital as she wanted to die at home.
The nurse has reviewed the hospice nurse
notes but has determined that the DNR
and advanced directives are out of date.
Ms. Knox's mental state is questionable
as she has been receiving Morphine.
1- Full assessment, focused on mental
status
2- Contact IV team
3- Set-up PCA
4- Contact HCP to see if they can apply a
PureWick, female external catheter
5- Contact social services
Hannah Knox Scenario 2
Hannah KnoxThe Pic-line has been
replaced by the IV team, but the nurse is
concerned about the plan to send Ms.
Knox home again. She caught the
granddaughter rummaging through Ms.
Knox's belongings, and asked the nurse
where the pain medication is. The nurse
explained that she is taking care of the
patient's pain, and has a gut feeling that
granddaughter may be a drug seeker.
The granddaughter asks if she can give
her grandma a cigarette.
1- Place patient on continuous pulse ox
2- Administer antibiotics and start
Morphine PCA with a basal rate of
4mg/hour, and demonstrate to patient
how to administer
3- Reassess effectiveness of PCA
4- Review medical history of pain
medications for dosage, frequency, and
effectiveness
5- Document
Hannah Knox Scenario 3
Hannah KnoxMs. Knox's respiratory status
has deteriorated over the last 24 hours.
She has been placed on a simple face
mask at 6L and is audibly wheezing.
There is an order for resp therapy to give
her albuterol breathing treatments and
prepare her for possible intubation. The
daughter wants everything to be done but
the patient has made it clear in the
hospice plan that she did not want to be
intubated. The social worker has told the
nurse that being at the hospital is the
best thing for the patient as the living
conditions at home are less than
desirable. The granddaughter's boyfriend
has a warrant out for his arrest.
1- Reassess vital signs and elevate head
of bed
2- Provide palliative care
3- Call respiratory therapy and assist with
treatments
4- Seek clarification about advanced
directives and DNR status
5- Provide emotional support for patient
and family and ask if they would like you
to contact a hospital chaplain
Hannah Knox Scenario 4
Hannah KnoxAfter a family conference
with the provider and the social worker it
is decided that Ms. Knox is an official DNR
and will not be intubated. Ms. Knox is
complaining of worsening pain, but her
respirations are very shallow and her
SpO2 is 89%. The provider tells the nurse
to increase her basal morphine rate to
8mg/hour, and place patient on 100%
non-rebreather mask. The nurse is
concerned as she understands that she is
in respiratory failure, but she does not
want to precipitate the patient's death
because of her increasing the morphine
rate.
1- Full assessment
2- Place patient on 100% non-
rebreather/10L ensuring the reservoir bag
is fully expanded
3- Review PCA pump history
4- DNR armband and tag on patient's
bed/wall
5- Discuss with HCP concerns of morphine
dose and respiratory status
Hannah Knox Scenario 5
Hannah KnoxAt 2am, Ms. Knox expires.
The daughter is grief stricken and
questions, "should we do something?".
The granddaughter is sitting outside the
door crying. Her boyfriend has just shown
up and is pacing outside the door and
seems agitated. The nurse is challenged
to provide post-mortem care for Ms.
Knox's body and comfort the family.
1- Contact HCP
2- Take patient's family to a quiet room
3- Contact chaplain
4- Prepare Ms. Knox body for final viewing
5- Notify social services that boyfriend is
present
Hannah Knox
Hannah Knox is a 62 y/o patient who has
been receiving hospice care for
metastatic lung cancer. She continued to
smoke until recently. The plan was for her
to die at home, but her daughter couldn't
handle having her in her home after 2
weeks of hospice care. The daughter was
complaining that her mother was in an
extreme amount of pain, and her family
could not cope. Ms. Knox is frail, weak,
and apprehensive about her care. Her
lung sounds are diminished in her lower
lobes bilaterally, and she has crackles in
her upper lobes. She is on 4L O2 nasal
canula. She has a pic-line in her right
arm. Vital signs BP: 98/52, P: 92, R: 30,
SpO2: 91, T:100.2F, 37.8 C
Alteration in comfort
Chronic discomfort
Fear
Knowledge deficit
Potential for alteration in gas exchange
Potential for infection
Carlos Mancia | Room 303
Patient Overview
carlos_mancia.jpgCarlos Mancia48yr-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
Educational Needs- Increased
Fall Risk- Increased
Health Change- Increased
Pain Level- Normal
Psychological Needs- Increased
Sensorium- Normal
Carlos Mancia Scenario 1
Carlos ManciaUpon entering the room,
you wash/glove hands. Following isolation
precautions, you notice several family
members are by his bedside and none of
them are wearing face masks as
requested by the sign on the door.
1- Obtain translator
2- Offer masks to visitors
3- Educate patient
4- Evaluate understanding
5- Obtain Spanish signs & brochure
Carlos Mancia Scenario 2
Carlos ManciaMr. Mancia is a non-English
speaking patient and is fearful of being
discovered as an illegal immigrant. Upon
entering the room with a translator to
admit him to the hospital, he is asked for
address and phone number but refuses to
comply.
1- Don Personal Protective Equipment
2- Obtain translator
3- Allow for non-compliance of patient
and do not probe further
4- Verify call Light/bed safety precautions
5- Document results
Carlos Mancia Scenario 3
Carlos ManciaBefore entering Carlos
Mancia room to administer his antipyretic
medication for his recent temp of 101.2
1- Obtain translator
2- Wash Hands
3- Put on gown and mask
4- Don Gloves
5- Administer antipyretic medication
Carlos Mancia Scenario 4
Carlos ManciaThe sister of Mr. Mancia
calls from home to speak with you. She
shares her concerns about the patient's
wife who is now coughing and having
night sweats.
1- Educate caller regarding HIPAA
2- Evaluate caller understanding
3- Refer caller to contact health
department
4- Notify doctor
5- Document conversation
Carlos Mancia Scenario 5
Carlos ManciaMr. Mancia is holding a
Catholic Rosary in his hand and is crying
as you enter the room.
1- Obtain translator
2- Use therapeutic communication/Active
Listening
3- Educate patient regarding diagnosis
and inform him of potiental for full
recovery
4- Evaluate learning
5- Document teaching moment
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
Alteration in gas exchange
Exhaustion
Ineffectual airway clearance
Anxiety
Fear
Knowledge deficit
Potential for falls
Potential for becoming socially isolated
Noncompliance
Readiness for improved self-care
Educational Needs-
Fall Risk-
Health Change-
Neurological-
Pain Level-
Psychological Needs-
John Davis
John Davis is a 54 y/o male admitted for
surgical resection and biopsy of multiple
lesions on his back and shoulders. The
patient is fair skinned with multiple moles
on his shoulders and anterior and
posterior torso. The patient is high risk for
basal cell carcinoma and has had mole -
mapping. Mr. Davis is very thin and
reports an 8 lbs. weight loss over the last
four months. He owns a landscape
business, works outside, he also enjoys
being out on his boat. He had a basil cell
carcinoma removed from his forehead
four years ago (Mohs micrographic
surgery) which has left a large scar. Mr.
Davis is concerned about potential scars
from these lesions. He denies any other
health issues. The patient does not
smoke, but drinks 2 beers after work daily
and more on the weekends. VS BP
150/89, P 62, R 14, T 98.2.
Knowledge deficit
John Davis Scenario 1
John DavisThe surgery went well, he had
one partial thickness lesion on his
shoulder and one of the lesions on his
back are full thickness that will require
staged closure or a possible skin graft. He
has a 4x4 dressing on his right shoulder,
two large dressings, and two smaller
dressings on his back. His vital signs are
stable. He has an IV NS to his left hand @
TKO. He received 2 liters intraoperatively.
He was given Fentanyl 100 mg and
Zofran 4mg in the PACU. The patient asks
if he can go to the bathroom because he
needs to void immediately.
1- Offer patient a urinal and assist to
bedside, if needed
2- Perform post-op assessment to include
visual inspection of dressings, vital signs,
pain
3- Assist patient to a comfortable position
in bed
4- Tell patient not to get out of bed
without assistance
5- Ensure side rails are up and call light is
within reach
1-
2-
3-
4-
5-
John Davis Scenario 2
John DavisThe patient has been made
aware that he has advanced basal cell
carcinoma and has a poor prognosis. The
largest dressing is saturated with serous
sanguineous fluid. The patient is
complaining of 8/10 pain from two of the
partial thickness incisions on his back (he
will need skin graft soon). Patient states
the larger dressings on his back that are
full thickness do not hurt at all. The
patient has an order for dressing changes
PRN. The patient is awaiting orders for
chemotherapy. VS BP 162/90, P 99, R 20,
T 98.9.
1- Assess the large dressing site (full
thickness)
2- Administer pain medication as ordered
3- Assess dressing supply needs and
obtain
4- Assess patient's need for emotional
support and evaluate effectiveness of
pain medication
5- Document color and amount of wound
drainage on dressing
John Davis Scenario 3
John DavisThe nurse's aide reports that
the Mr. J did not eat any of his lunch or
dinner. The surgeon and oncologist had
visited with the patient that morning.
When the patient is asked about his
appetite the patient states that he is
nauseated. The SL is occluded. The orders
came to initiate Chemotherapy:
vismodegib (Erivedge) is 150mg orally
daily. The sonidegib (Odomzo) dose is
200 mg orally daily taken on an empty
stomach, at least 1 hour before or 2 hours
after a meal. Zofran 4mg IV PRN
1- Restart new IV
2- Administer nausea medicine
3- Assess for contraindications to
Chemotherapy
4- Weigh the patient and verify dosage
5- Take VS and provide patient teaching
on chemotherapy prior to infusion.
John Davis Scenario 4
John DavisThe nurse is still concerned
about the patient's appetite the next day,
3 days post-op. The patient will be seeing
an oncologist before his discharge and
the surgeon has stated that he will need
to have several more lesions removed
ASAP. The patient has learned that his
cancer is stage 4 basal cell and has
metastasized. He has not been
ambulating and has been laying on his
back most of the time. When changing
the dressings, the nurse notices that the
one of wounds on his back appears
inflamed and reddened as well. VS BP
150/80, P 82, R 14, T 100.8
1- Complete full assessment and inspect
patient's wounds
2- Apply clean dressing to all wounds
3- Encourage patient to change body
position and not lie on wounds
4- Continue to encourage nutrition and
fluids
5- Document and inform HCP of wound
changes
John Davis Scenario 5
John DavisThe doctor has chosen to
pursue a more aggressive chemotherapy
agent related to metastasizing cancer
and side effects (muscle cramps and
gastrointestinal discomfort). The patient
will continue chemotherapy after
discharge and is being counseled for the
placement of a peripherally inserted
central catheter (PICC) and why he needs
it. The patient will be receiving his
chemotherapy from an outpatient
infusion clinic. The patient is still not
eating and seems complacent in his care.
When inquiring about his support system
the patient states that running a business
does not allow much time for friends or
family.
1- Assess patients concerns and
understanding plan of care and current
treatment
2- Teach patient about the benefits of a
picc line with chemotherapeutic agents
3- Make referral to the infusion clinic to
verify appointments
4- Discuss with patient if he has any
transportation
5- Have patient verbalize understanding
of treatment and future needs and
services
Lithia Monson | Room 301
Patient Overview
lithia_monson.jpgLithia Monson93 years
old, came to us yesterday with a fall at
the nursing home with a suspected
subdural hematoma. She seems stable,
difficult to determine her level of
confusion as she has dementia. She has a
bump on her head. Ms. Monson is
cooperative, direct-able, and we do not
see any changes. Vital signs are stable -
Temp 97.2, BP 96/74, P 82, RR 20, SaO2
97%. She is oriented with some direction
to time and place. Her speech is clear.
She did not recognize her son today when
he came to see her, but that is not new
for her. Q1 hour nuero assessments and
we are watching her closely. We have
asked the family to stay with her 100% of
the time so she does not fall. Strict I&O,
Hep-Lock in place left AC although no IV
therapy going. Ms. Monson is a patient of
Dr. Altace
Educational Needs- Increased
Fall Risk- Increased
Health Change- Increased
Pain Level- Normal
Psychological Needs- Increased
Sensorium- Increased
Lithia Monson
Lithia Monson 93 years old, came to us
yesterday with a fall at the nursing home
with a suspected subdural hematoma.
She seems stable, difficult to determine
her level of confusion as she has
dementia. She has a bump on her head.
Ms. Monson is cooperative, direct-able,
and we do not see any changes. Vital
signs are stable -Temp 97.2, BP 96/74, P
82, RR 20, SaO2 97%. She is oriented
with some direction to time and place.
Her speech is clear. She did not recognize
her son today when he came to see her,
but that is not new for her. Q1 hour nuero
assessments and we are watching her
closely. We have asked the family to stay
with her 100% of the time so she does
not fall. Strict I&O, Hep-Lock in place left
AC although no IV therapy going. Ms.
Monson is a patient of Dr. Altace
Alteration in nutrition
Potential for bleeding
Self-care deficiency
Acute Confusion
Potential for falls
Failure to Thrive
Lithia Monson Scenario 1
Lithia MonsonYou arrive in room to find
Ms. Monson talking to herself. Upon
assessment, you determined that she is
confused to person, time, and place but is
easily directable.
1- Perform neuro assess
2- Reorient Patient to person, place, &
time
3- Assess for fall risk
4- Offer nutrition/toilet
5- Discuss effectiveness of sitter
Lithia Monson Scenario 2
Lithia MonsonA special lowbed has been
ordered that will lower to the ground. The
bed arrives tomorrow. You are concerned
about preventing the patient from falling.
1- Complete neuro checks as ordered
2- Discuss and determine sitter
availability
3- Check on patient/sitter hourly
4- Advise sitter to notify nurse when
leaving the room
5- Determine when a hospital provided
sitter will be necessary
Lithia Monson Scenario 3
Lithia MonsonA few hours after speaking
with the sitter about the patient needing
complete observation, you notice the
sitter outside of the room talking on the
phone. Upon entering the room, the
patient appears to be trying to get out of
bed
1- Reassess patient
2- Ensure patients is positioned in bed
properly
3- Discuss with sitter that patient needs
continual observation
4- Discuss with family sitter if there are
any other family members who can help
with monitoring Lithia
5- Document and contact nursing
supervisor/Charge nurse
Lithia Monson Scenario 4
Lithia MonsonPrior to changing shift, you
enter the patient's room to complete a
full assessment, and Ms. Monson is now
crying asking to for someone to take her
home!
1- Complete full assessment, to include
neuro
2- Use therapeutic communication/active
listening
3- Attempt to orient to person, place, and
time
4- Offer nutrition and/ or toileting
5- Ensure bed is in lowest position, and
rails are in place
Lithia Monson Scenario 5
Lithia MonsonWhen completing the shift
change neuro check, you notice the
patient's left pupil is sluggish. You also
notice the patient is more difficult to
orient.
1- Notify HCP of neuro findings
2- Notify charge nurse of patient's
deteriorating condition
3- Begin q15 minute neuro checks
4- Have patient remain in bed, head
elevated 30 degrees
5- Ensure IV is patent
1-
2-
3-
4-
5-
Donald Lyles | Room 302
Patient Overview
donald_lyles.jpgDonald Lyles52-year old
male, was admitted yesterday evening for
stabilization of his uncontrolled type II
diabetes. He is married, and his wife is
requesting to stay at his side. His HbgA1c
is 10.6%. He has a history of a Myocardial
Infarction, MI, one year ago, and has
refused all cardiac rehab, and has not had
another cardiac event. He refuses to
comply with dietary recommendations.
His BMI is 37. Vital signs are: BP: 146/94,
P: 88, R: 22, T: 99.2, PaO2: 94% Blood
glucose upon admission is 340 mg/dl
Educational Needs- Increased
Fall Risk- Normal
Health Change- Increased
Neurological- Normal
Pain Level- Normal
Psychological Needs- Normal
John Duncan | Room 303
Patient Overview
john_duncan.jpgJohn Duncan56yr-old
male, Dx- Gastroenteritis, returned
yesterday from Cancun, c/o intractable
diarrhea, weak, pale, and refusing to eat.
No known allergies (NKA). Non-significant
past medical Hx. Vital signs Temp 99.4,
BP 106/72, P 96, RR 20, SaO2 91%. Neuro
WNL's, alert and cooperative. IV
maintenance fluids with D5 1/2 NS at
125ml per hour in left forearm. c/o
headache- medicated with Lortab 5mg PO
at 0900, takes Lomotil 10ml PRN q 4
hours last dose at 0834. Stools are
decreasing but patient remains very
weak. Wife at bedside. Diet as tolerated.
Dr. Jones.
Educational Needs- Increased
Fall Risk- Increased
Health Change- Increased
Pain Level- Increased
Psychological Needs- Normal
Sensorium- Normal
Donald Lyles Scenario 1
Donald LylesMr. Lyles calls you via the
call light. Upon entering the room, he
asks if you have medication for
"heartburn". He says, "I take TUMS at
home when this happens." You tell the
patient you will be glad to check-on what
is available for relief of his "heartburn"
after you complete his physical
assessment. You begin his assessment,
and he falls back in the bed and becomes
unresponsive. You shout, "Are you okay?
Are you okay?"
1- Establish responsiveness.
2- Call for Rapid Response/CODE-blue.
3- Check for breathing and carotid pulse.
4- Begin continuous chest-compressions
until help arrives.
5- When help arrives, pass off chest
compressions and begin respirations.
Donald Lyles Scenario 2
Donald LylesThe CODE-blue team arrives
with a crash cart, Physician, Anesthetist,
and 2 critical-care nurses, and 1
Respiratory therapist.
1- Assist with airway management.
2- Assist with applying ECG leads.
3- Establish large IV access.
4- Provide patient history of event to
team.
5- Provide medical history - including
medication history and allergies.
Donald Lyles Scenario 3
Donald LylesYou have now been assigned
to document the ongoing event as the
CODE team continues with the
resuscitation.
1- Check time from one source.
2- Establish when the cardiac event time
began.
3- Document rhythm used to determine
medications to be administered.
4- Begin list of medications and time/dose
given.
5- Remind CODE team to stop CPR and
check for pulse Q5 minutes.
Donald Lyles Scenario 4
Donald LylesAfter 15 minutes, the
patients rhythm returns, but he is still
unresponsive. He is now in Ventricular
tachycardia with a weak pulse, and a BP
of 70/40. Prepare to initiate Cardio-
version.
1- Ensure cardio-pads are in place
anterior chest and posterior back.
2- Charge the monitor to 200 J biphasic.
3- Announce to CODE team that you are
ready to cardiovert.
4- Announce "CLEAR, CLEAR, EVERYONE
CLEAR".
5- Ensure no one in the room is touching
the patient or the bed and cardiovert.
Donald Lyles Scenario 5
Donald LylesMr. Lyles responded to the
first cardioversion, and is now in sinus-
bradycardia with a second-degree heart
block. He is still unresponsive. Vital signs
are BP:80/40, P: 46, R:16 (patient now
intubated, and ventilated by Respiratory
Therapy).
1- Give 1mg of Atropine, IVP as ordered
by Provider.
2- Reassess patients vital signs in 3-5
minutes: BP: 85/44, P: 52, R:16 (patient
intubated, and ventilated by Respiratory
Therapy).
3- Repeat 1mg of Atropine administration
within 3-5 minutes of first dose.
4- Prepare for external pace-maker
placement.
5- Document and accompany patient to
ICU immediately, and handoff report to
receiving ICU nurse.
Donald Lyles
Donald Lyles 52-year old male, was
admitted yesterday evening for
stabilization of his uncontrolled type II
diabetes. He is married, and his wife is
requesting to stay at his side. His HbgA1c
is 10.6%. He has a history of a Myocardial
Infarction, MI, one year ago, and has
refused all cardiac rehab, and has not had
another cardiac event. He refuses to
comply with dietary recommendations.
His BMI is 37. Vital signs are: BP: 146/94,
P: 88, R: 22, T: 99.2, PaO2: 94% Blood
glucose upon admission is 340 mg/dl
Knowledge Deficit
Potential for infection
John Duncan Scenario 1
John DuncanAs you enter the room, Mr.
Duncan is refusing to eat foods from
bland diet.
1- Assess intake and output and possible
reasoning
2- Construct dietary consult (plan)
3- Acquire daily weight and food intake
4- Evaluate outcome of dietary plan
John Duncan Scenario 2
John DuncanMr. Duncan is now
complaining of feeling "dizzy" when he
stands.
1- Full assessment including both
lying/standing
2- Check input/output for possible
dehydration
3- Teach patient about safety when
getting out of bed
4- Document findings
John Duncan Scenario 3
John DuncanSeveral hours later, Mr.
Duncan is now complaining of nausea.
1- Wash and glove hands
2- Provide emesis basin/cloth
3- Vital sign assessment
4- Administer antiemetic medication
5- Evaluate medication effectiveness
John Duncan Scenario 4
John DuncanTwo hours later, Mr. Duncan
is asked how frequent his stools have
been today. He replies, "six times in the
past four hours". He also states he is
feeling weak.
1- Vital sign assessment
2- Assessment of bowel movement
3- Administer protocol antidiarrheal
medication
4- Document results/findings
5- Include patient condition change in
shift report
John Duncan Scenario 5
John DuncanMr. Duncan's wife meets you
in hall asking what she could bring her
husband to eat from home.
1- Inform and educate spouse of dietary
orders
2- Evaluate/modify plan of care
3- Assess food consumption and intake
and output
4- Document findings/results
Paul Greer | Room 304
Patient Overview
Paul Greeris a 57 y/o who has been
admitted for a radical prostatectomy. He
was recently diagnosed with stage III
prostate cancer. His original lymph node
biopsy was negative. He has a history of
hypertension and is not compliant with
medication. Until the recent diagnosis of
cancer, the patient had only seen a
physician once in the last ten years. He
has a 20-year one pack history of
smoking. However, he quit three years
ago when he remarried; he and his wife
have a nine-month-old baby. His difficulty
voiding finally motivated him to seek
care.
Educational Needs- Increased
Fall Risk- Normal
Health Change- Increased
Pain Level- Normal
Psychological Needs- Normal
Sensorium- Normal
John Duncan
John Duncan 56yr-old male, Dx-
Gastroenteritis, returned yesterday from
Cancun, c/o intractable diarrhea, weak,
pale, and refusing to eat. No known
allergies (NKA). Non-significant past
medical Hx. Vital signs Temp 99.4, BP
106/72, P 96, RR 20, SaO2 91%. Neuro
WNL's, alert and cooperative. IV
maintenance fluids with D5 1/2 NS at
125ml per hour in left forearm. c/o
headache- medicated with Lortab 5mg PO
at 0900, takes Lomotil 10ml PRN q 4
hours last dose at 0834. Stools are
decreasing but patient remains very
weak. Wife at bedside. Diet as tolerated.
Dr. Jones.
Decrease in fluid volume
Exhaustion
Potential for alteration in electrolyte
balance
Potential for falls
Noncompliance
Educational Needs-
Fall Risk-
Health Change-
Neurological-
Pain Level-
Psychological Needs-
Sensorium-
Paul Greer Scenario 1
Paul GreerMr. Greer has just returned
from surgery. The cancer was more
advanced than they previously had
thought so inguinal lymph nodes were
removed. The surgeon believes that the
surgery was successful but recommends
the patient have chemotherapy and
radiation postoperatively. The patient has
a Foley catheter in place and is reporting
8/10 incisional pain and he is asking why
his throat is sore. VS: BP 158/90, HR 89, R
18, T 97.8 F.
1- Complete initial post-op assessment
2- Check patency of Foley catheter, urine
color, and ensure it is secure to the
patient's leg
3- Medicate for pain
4- Explain to patient why his throat may
be sore
5- Inform patient to not get out of bed
without assistance and place call light in
reach
Paul Greer Scenario 2
Paul GreerWhile assessing the patient,
Mr. Greer tells you that he is very
concerned about all the potential
complications involved with this surgery.
He is aware that he may not have an
erection and may need Depends Briefs for
bladder incontinence.
1- Inform the patient his apprehension is
expected with this surgery/diagnosis.
2- Explain to Mr. Greer that it may take
several days for healing, and he may
have temporary incontinence, but it will
resolve over time.
3- Teach the patient that there are
several interventions for complications
post-prostatectomy to include erectile
dysfunction, post-op prostatectomies, and
self-care involved with a foley catheter at
home.
4- Evaluate patient's understanding of
teaching
5- Continue to observe urine for
hematuria and document findings
Paul Greer Scenario 3
Paul GreerThe surgeon has just visited
with Mr. Greer 2-days post op and has
informed him that the lymph node
biopsies have confirmed that the cancer
has metastasized, and he will need
further treatment. The surgeon has
suggested Androgen-deprivation therapy
(ADT) with surgical castration
(orchiectomy). The patient tells the nurse
that yesterday he was, "concerned about
having an erection, and now they want to
cut off my testicles". He tells the nurse he
has called his wife and wants to be
discharged now.
1- Using therapeutic communication
inform Mr. Greer that there are many
treatment options, and not to leave until
the HCP can come and speak with him
2- Contact HCP to determine when they
are available to speak with the patient
3- Provide the patient with the time when
HCP will come discuss options with him
4- Provide a diversional activity to pass
the time while waiting on the HCP and
inform wife that the HCP will be coming
soon
5- When the HCP arrives, stay in the room
to determine whether you can continue
care with the patient
Paul Greer Scenario 4
Paul GreerThe emergency bathroom light
goes off and the nurse finds Mr. Greer on
the floor in the bathroom. The patient got
dizzy when he stood up from the
commode. Mr. Greer is on the floor still
but is awake and oriented and is
complaining of back pain below his right
scapula.
1- Complete head-to-toe assessment
while patient is on the floor.
2- Ensure patient privacy and call for help
and assist patient to bed once help
arrives
3- Complete secondary assessment once
the patient is in bed focusing on
complaint of pain resulting from the fall
4- Reinforce to the patient to not get out
of bed
5- Notify HCP of fall, complete incident
report
Sarah Getts | Room 303
Patient Overview
sarah_getts.jpgSarah Getts77 yr-old, Dx-
Chronic Renal Failure, admitted with
hyperkalemia (5.9, Eq/L)/hyponatremia
(128mEq/L). No known allergies (NKA).
Vital signs -Temp 98.8, BP 102/76, P 102-
irregular, RR 22, SaO2 90%,
cardiovascular on telemetry with Sinus
irregular rhythm. Disoriented to time and
place, speech slurred. Pupils PERRLA,
eyes clear. 20 ga. Hep-Lock in right
forearm, skin warm and dry, generalized
weakness with recent weight loss. 50%
intake. High fall risk. Renal diet. Family in
room with patient very concerned. Dr.
Brown
Educational Needs- Increased
Fall Risk- Increased
Health Change- Increased
Pain Level- Normal
Psychological Needs- Increased
Sensorium- Increased
Cameron Daniels
Cameron Daniels just turned 18 y/o. She
is being admitted from the ER with a
diagnosis of pelvic inflammatory disease
(PID). She has heavy vaginal discharge
with an unpleasant odor. She is
complaining of abdominal pain and looks
pale. She was seen by OBGYN in the ER
and a culture was sent to the lab for
Chlamydia and Neisseria Gonorrhea. She
was a very difficult IV start and has a 23g
saline lock (SL) in her right hand. They
have ordered a liter bolus of LR, but it is
running very slowly and the IV is
positional. VS BP 96/58, P 116, R 18, T
101.2 PaO2 98%.
Acute discomfort
Alteration in mobility
Knowledge deficit
Potential for falls
Potential for infection
Cameron Daniels Scenario 1
Cameron DanielsCameron is on the Med-
Surg floor and complaining of 9/10
abdominal pain. Her pregnancy test is
positive, and the provider is concerned
that it may be ectopic and has scheduled
an ultrasound. She has an order for
Tylenol 1 gm for T > 99.0. The IV barely
running and the IV pump keeps alarming
occluded. She has only received 500 ml of
her Liter bolus. She also has an order for
Cefotan (Cefotetan) 2 g intravenously IV
every 12 hours and Oracea (Doxycycline)
100 mg by mouth every 12 hours. VS BP
96/58, P 116, R 18, T 101.2 PaO2 98%.
1- Give Tylenol 1g
2- Start another IV then DC the first.
3- Initiate bolus and medications
4- Request additional pain med order
from the HCP
5- Reassess temperature in 1hr
Cameron Daniels Scenario 2
Cameron DanielsThe nurse is speaking
with the Cameron about her diagnosis.
The cultures were positive for chlamydia
and gonorrhea. She asks the nurse how
she got this infection. The patient had
denied being sexually active in the ER.
Cameron finally tells the nurse that she
has been seeing an older married man
from their church for few years, and they
are in love. Once realizing the patient just
turned 18 the nurse asks her how many
years this relationship has been going
and the patient tells her 3 years.
1- Sit at an eye level with the patient
using nonjudgmental therapeutic
communication
2- Teach Cameron concerning the
complications of PID, STIs, and infectious
disease.
3- Evaluate patient understanding of STIs
and unprotected sex
4- Contact the charge nurse / law
enforcement and inform them about the
potential legal issues.
5- Document patients' statement and
prepare a written report.
Cameron Daniels Scenario 3
Cameron DanielsThe provider is visiting
with Cameron and informs her that her
pregnancy test is positive, and they are
concerned that it may be ectopic. The
patient becomes very upset and admits
that she has been also seeing more than
one individual as she also had sex with a
boy from her high school, "but it was just
one time". She asks the nurse not to tell
her mother. Later that day Cameron is
visited by a young man who brings her
flowers. The nurse overhears the patient
telling her visitor that she had
appendicitis and she will be well soon.
1- Provide emotional support and ask
open ended nonjudgmental questions.
The nurse should establish trust first.
2- Assure patient that as an adult her
medical information is private unless she
gives consent for release to other
individuals. Cameron has just turned 18
but still lives at home, therefore she is
transitioning into the mindset off an adult.
3- Explain to the patient that she has a
sexually transmitted infection and while
her patient information is private this
type of infection is required to be
reported to the Department of Health. As
an adult she she has the right to privacy
but this disease has consequences.
4- Stress the importance of informing any
sexual partners of her STI as they may
transmit the infection.
5- Inform patient that you will set-up a
one-on-one with a pregnancy counselor to
discuss her pregnancy to include a
description of an ectopic pregnancy
Cameron Daniels Scenario 4
Cameron DanielsThe ultrasound was
positive for an ectopic pregnancy and the
provider has ordered methotrexate 1.0
mg/kg in two divided doses. Cameron's'
mother comes to visit and is insisting that
she be allowed to talk to the doctor in
private. She also asks if she can spend
the night. The mother states that they are
very religious, and she has invited their
pastor to come by to pray for her
daughter. The mother does not know
about the ectopic pregnancy nor
understand Cameron's diagnosis or social
circumstances. She is requesting
information about Cameron's diagnosis.
1- Make sure you have an accurate
weight on the patient and verify the
prescribed dosing.
2- Explain the reason for the medication
(in private) to include potential side
effects, to include nausea, vomiting,
headaches, fatigue, and an overall "blah"
feeling.
3- Tell the mother that you understand
her concern as a mother, but her
daughter is an adult and discussing her
diagnosis would violate HIPAA
4- Tell the mother that visitors are
welcome, but she can only spend the
night if her daughter approves
5- Be honest with Cameron concerning
the need for family support and inform
her that the mother is very concerned
and has asked to spend the night. Inform
her that her mother has also asked the
pastor to come pray with her.
Cameron Daniels Scenario 5
Cameron DanielsThe nurse is preparing to
discharge Cameron the next day. The
mother and father want to hear the
discharge instructions. Cameron asks to
be allowed to speak with her parents
privately. After a few minutes there are
shouts heard from the room with the
patient screaming, "No"! The father is
seen by the nurse running out of the
room and heard stating, "I'm going to kill
that bastard"! The nurse runs in the room
and Cameron is sobbing with the mother
at her side. The IV has been pulled out
and there is blood on the floor.
1- Assess patient, apply a dressing over
the IV site to stop the bleeding, and call
for additional support to the room.
2- Perform a rapid assessment of the
patient to ensure she was not injured
3- Ask the patient if she was physically
assaulted by her father
4- Inform the charge nurse to call a code
Gray (Security)
5- Call the local law enforcement to make
a report
Cameron Daniels | Room 301
Patient Overview
cameron_daniels.jpgCameron Danielsjust
turned 18 y/o. She is being admitted from
the ER with a diagnosis of pelvic
inflammatory disease (PID). She has
heavy vaginal discharge with an
unpleasant odor. She is complaining of
abdominal pain and looks pale. She was
seen by OBGYN in the ER and a culture
was sent to the lab for Chlamydia and
Neisseria Gonorrhea. She was a very
difficult IV start and has a 23g saline lock
(SL) in her right hand. They have ordered
a liter bolus of LR, but it is running very
slowly and the IV is positional. VS BP
96/58, P 116, R 18, T 101.2 PaO2 98%.
Educational Needs- Increased
Fall Risk- Increased
Health Change- Increased
Neurological- Normal
Pain Level- Increased
Psychological Needs- Normal
Paul Greer Scenario 5
Paul GreerMr. Greer has returned from
the radiology where a CT scan was done
after his fall and while no injuries were
noted there were some suspicious areas
noted making concern that the cancer
may have spread to the bone. Because of
the fall the provider has recommended
that he stay in the hospital another night.
The oncologist is recommending
Docetaxel as opposed to an orchiectomy.
They would also like to start Radium-223.
The oncologist is insistent that the
treatment begin immediately. The patient
asks the nurse to explain about these
medications and why they are in such a
hurry. His children are visiting, and they
are very supportive.
1- Ask the patient if it is okay to discuss
his care in front of his children.
2- Explain that Docetaxel is a hormone
therapy that suppresses the testosterone
that your testicles produce producing
similar results as surgical intervention.
3- Explain that Radium-223 mimics
calcium and is absorbed during new bone
growth. This will treat any cancer that
may have metastasized to the bone.
4- Ask the patient to verbalize
understanding of teaching and reassure
them that yourself or any member of their
care team will be available to answer
questions.
5- Evaluate patient's understanding of the
teaching and discuss home support
Dana Fitzgerald Scenario 1
Dana FitzgeraldPreoperatively Ms.
Fitzgerald is very nervous. When the
nurse enters the room, she appears to
have been crying. She confides in the
nurse that she was hoping to try one
more time to have a baby, but now there
is no hope. She tells the nurse they are in
the process of adopting but is concerned
that the mass may be cancerous,
although the surgeon has assured her
that they do not expect any malignancy
1- Sit with the patient and provide
emotional support by using open-ended
questions.
2- Reinforce provider teaching that fibroid
uterine masses are rarely cancerous.
3- Reassure the patient that she can
make a full recovery from surgery, and it
should not interfere with the adoption
process.
4- Assess adequate family support system
prior to discharge
5- Ask the patient if they would like to
speak with a clinical counselor or
chaplain.
Dana Fitzgerald Scenario 2
Dana FitzgeraldMs. Fitzgerald returns
from surgery. The surgery went well, and
multiple large fibroid masses were found
on her uterus with several ovarian cysts.
There were no signs of cancer, and the
initial pathology report was negative. She
is very stoic, but the nurse suspects she
is in severe pain. She was given 100 mg
of fentanyl IVP in the PACU. The patient
has an order for Fentanyl 25 mg IVP q two
hours for pain. A PCA pump has been
ordered, but no PCA pumps are available
on the floor—advance diet as tolerated.
The nurse notices that there is no order
for Colace. The patient states need to
void, but she has a foley catheter in
place. VS BP 139/79, P 88, R 18, T 99.2.
1- Head to toe assessment to include
surgical site
2- Inspect catheter to ensure it is not
obstructed/kinked
3- Teach patient that the catheter makes
it feel like she needs to void
4- Instruct patient not to get up without
assistance. Administer pain medication
and ensure side rails are up, the bed is in
the lowest position, and the call light is
within reach.
5- Ask the charge nurse for help locating
a PCA from another floor. Then, obtain an
order for Colace and inform the provider
that you are trying to find a PCA pump.
Dana Fitzgerald Scenario 3
Dana FitzgeraldMs. Fitzgerald has been
resistant to ambulation post-op day 2.
Her abdominal pain is 8/10, and her
husband tells the nurse she just needs to
rest and get her pain medication on time.
She has been resistant to use the
incentive spirometer as well. When the
nurse inspects her abdomen, the dressing
is dry and intact, but her abdomen is rigid
and slightly distended. Her bowel sounds
are hypoactive, and her urine is very
dark. VS BP 132/80, P 95, R 20, T 100.2.
1- Teach the patient that the pain
medication works best if she ambulates
and uses the incentive spirometer after
the pain medication is administered.
2- Explain to the patient the importance
of the incentive spirometer q15 minutes.
Instruct the patient and husband that she
does not ambulate without assistance and
to call for help.
3- Administer pain medication and have
the patient demonstrate incentive
spirometer technique. Teach patient how
to use a pillow as an abdominal splint
while coughing and deep breathing
4- Tell the patient that she must drink
plenty of fluid To be hydrated for
ambulation.
5- Have the patient ambulate a short
distance with your assistance.
Dana Fitzgerald Scenario 4
Dana FitzgeraldOn the third day post-op,
Ms. Fitzgerald's pain is 9 /10, and the
patient states it is a stabbing pain that
comes in waves. She has not been eating
due to nausea and has only drunk 100 ml
in the past 8 hours. The patient states her
last bowel movement was two days
before her operation. The nurse needs to
perform an abdominal examination and
encourage ambulation. The husband has
become very concerned about surgical
complications and insists that she be
given pain medication and left alone to
rest. The nurse is concerned that she is
severely constipated and must rule out
bowel obstruction.
1- Inspect the patient's abdomen
2- Auscultate starting at the right lower
quadrant beginning at the right lower and
continuing to all others
3- Percuss and palpate all quadrants as
tolerated.
4- Contact provider before administering
additional pain medication.
5- Tell the husband and patient you have
notified the HCP and are doing further
assessments
Dana Fitzgerald Scenario 5
Dana FitzgeraldThe provider ordered a
KUB, revealing a large amount of stool
and gas, with no free air under the
diaphragm.. A digital rectal exam reveals
some very hardened stool and internal
hemorrhoids. The provider tells the nurse
Ms. Fitzgerald is severely constipated and
orders a fleets enema. In addition, the
provider will be sending her home with
medication for opioid-induced
constipation, Prucalopride, a prokinetic
drug that has been commercially
available in recent years for the
treatment of chronically constipated
patients.
1- Inform the patient that the pain
medication worsens her constipation, and
the fleets' enema has been ordered.
2- Provide patient privacy and lay the
patient on their left lateral side.
3- Lubricate the tip of the enema tip or
catheter and insert it into the rectum
gently.
4- Squeeze the content into the rectum
while telling her to take slow deep
breaths
5- Have the patient lay on their side and
retain an enema if they can tolerate it.
Then, assist the patient to commode or
onto a bedpan.
Dana Fitzgerald
Dana Fitzgerald is a 42-year-old gravida 5
para 0 patient admitted for a total
abdominal hysterectomy with bilateral
saplingo-oophorectomy (TAHBSO). She
has a history of endometriosis and uterine
fibroids for ten years. She has a
background history of subfertility with
multiple miscarriages. She has been
experiencing abdominal pain with heavy
menses over the last 6 months. A mass
has become palatable just below her
umbilicus. She has also been
experiencing dyspareunia during
intercourse. She also has a history of IBS
with opioid-induced chronic constipation.
She is otherwise healthy with some minor
anemia. VS: BP 128/62, P 72, R 16, T 98.6
F.
Knowledge deficit
Potential for grief
Potential for infection
Dana Fitzgerald | Room 302
Patient Overview
Dana_Fitzgerald.jpgDana Fitzgeraldis a
42-year-old gravida 5 para 0 patient
admitted for a total abdominal
hysterectomy with bilateral saplingo-
oophorectomy (TAHBSO). She has a
history of endometriosis and uterine
fibroids for ten years. She has a
background history of subfertility with
multiple miscarriages. She has been
experiencing abdominal pain with heavy
menses over the last 6 months. A mass
has become palatable just below her
umbilicus. She has also been
experiencing dyspareunia during
intercourse. She also has a history of IBS
with opioid-induced chronic constipation.
She is otherwise healthy with some minor
anemia. VS: BP 128/62, P 72, R 16, T 98.6
F.
Educational Needs- Increased
Fall Risk- Normal
Health Change- Increased
Neurological- Normal
Pain Level- Increased
Psychological Needs- Normal