SETON HALL UNIVERSITY COLLEGE OF NURSING

Clinical Make-up #4
Each question is worth 4.5 points. You need 85/100 for this assignment to count as a makeup assignment. Please submit via email by the date specified.
Verbal report from night nurse:

Forty year old Welbeck, Christy, DOB 3/13/1975, was

admitted to your floor at 4am this morning with Cholecystitis. Her medical history are Type II
DM and Migraine. She came in awake, alert and oriented x 3, complaining of severe abdominal
pain for the past three days. Per patient, she vomited x 2 yesterday and called the ambulance
because the pain became unbearable and she started experiencing generalized weakness. On
admission, she complained of RUQ pain of 8 out of 10 and was medicated with Morphine 2 mg
IV at 0430 hours. Her vital signs at the time including blood sugar were as follows: Temp- 101,
BP 137/87 HR 100, RR -22, Oxygen saturation 96%, blood sugar 150. She also received
Tylenol 650 mg at 0430 hours with sip of water. Since then patient slept and has not complained
of pain. Her temperature came down to 100.2 about one hour after Tylenol administration. She
remains alert and oriented x 3, ambulating to the bathroom. She is NPO awaiting attending
physicians consult. She has NS infusing at 100cc/hour via the RAC # 20 angiocatheter. Her
allergies are Aspirin and Sulphur.
The intern just ordered Ampicillin Sulbactam (Unasyn) 3grams IVPB Stat, then 2 grams every 6
hours and Heparin 5000 units every 12 hours. I did inquire about sliding scale but the intern said
we should continue monitoring the sugar whilst he consults her superior about that. I called
pharmacy to send medication so please administer that when you receive it. It is now 0730 and
you have just gotten out of report.

1. After receiving report, what is your first action? Assess the patient from head to toe, and
then do a focus assessment of the heart, lungs, and abdomen. Assess the patient for pain
using a pain scale. If the patient is experiencing pain administer the prescribed pain
medication to the patient. Also assess pain for nausea and see if the doctor can order a
anti-nausea medication. Assess the skin for wounds, rashes, bruises, infections or
breakdowns.
2. Which medications would you give and which medications would you hold? Why? I
would give the morphine because it helps to reduce pain. Tylenol for the fever. Antibiotic
to treat the infectious process and reduce inflammation. I wouldnt give the heparin
because it interacts with ampicillin sulbactam causing an increase risk for bleeding.
3.

What kind of consult would you expect to examine your Ms Welbeck? Why? Surgical
consult because the patient needs to have her gallbladder and any stones located in the
gallbladder or cystic duct removed.

4. It is now 11:15, the consulting physician has not called and you check your patients
blood sugar results 120, you do not have an ordered sliding scale which physician would
a.
b.
c.
d.
5.

you call:
Gynecologist
Internal Medicine
Surgeon
Podiatrist
You receive the following sliding scale, how much regular insulin coverage would you
administer for blood sugar of 201? ___4 units _____. What would you do if using the
sliding scale below, your patients blood sugar is 175? Call MD

Blood Glucose Level

(mg/dL)

Regular Insulin

Less than 70 mg/dL

Call MD
201-250 mg/dL
4 units
251-300 mg/dL
6 units
301-350 mg/dL
8 units
351-400 mg/dL
10 units
Greater
than
400Call MD
mg/dL
6.

Considering that your patient is NPO what route would you suggest for giving pain

medication? __IV ________________

7. It is now 1200 what assessments would you perform on Ms Welbeck? Pain assessment
and focus assessment on abdomen, lungs, heart. If the patient is in pain, use the pain scale
and then administer pain medication. I would as re-check the blood sugar.
8. It is now 12:15, you receive report on another patient transferring to your unit from ICU,
Kathy Kit, 45 year old female, hit by a car while crossing at an intersection, vitals 172/90,
pulse 90, resp 28, temp 98.9, she has a laceration on the posterior aspect of her head,
dressing clean and dry, half normal saline infusing at 75ml/hr. The nurse is in a hurry
because she is receiving other patients from the ER and would like to know if you can
read the chart for the history and other data, what questions would you still need to ask in
addition to what can be found in the chart? I would need to ask about patients medical
history and family history, allergies, medications, age, hospital visits, and past surgeries.
Is the patients airway patent? Is the patient breathing effectively? Is the patient circulation
effective? I would ask the patient how the accident happen and how the head became
lacerated. Did the patient loss consciousness? What are the vital signs? (Temperature,
pulse, respiration, blood pressure, o2 saturation, Glasgow come scale), what are the lab
results? Any x-ray testing and labs? Is the patient on oxygen or fluids? Does the patient
have tetanus shot? What was the last thing or time the patient ate? I would want to do a

neuro assessment to make sure the patient is alert and oriented x3. I would do this to
make sure the patient can make informed decisions or if Ill need to find a family member
to make medical decisions.
9. What risk factors exist for this patient? The patient is at risk for internal bleeding,
infection, and loss of consciousness.
10. You are now aware that this patient has a health history of mitral valve prolapse, coronary
artery disease, A-fib, hypertension and sutures to the posterior wound. What orders do
you expect the patient to have? Heparin (decrease risk of stroke), beta-blockers ,
prophylactic ASA, cardiac diet, CT or MRI scans, blood test.
11. What diet order would this patient have? Cardiac diet low sodium.
12. What teaching would you expect to do with this patient? If the patient smokes, I would
suggest the patient quits. I would teach the patient about their medications and how to
take them. How to recognize signs of stroke such as weakness, or numbness of the face,
arm or leg, especially one side, confusion, trouble speaking and understanding, trouble
walking, dizziness, loss of balance or coordination, and severe headache. Teach the
patient how to eat healthy by following a low-sodium and low fat diet, avoiding alcohol
and caffeine. Be active and do a reasonable level of exercise that they can tolerant. How
to reduce stress such as doing deep breathing exercises, meditation, yoga, and adequate
sleep.
13. Ms Welbecks call light is on, upon entering her room you see her leaning forward in the
bed moaning in pain, what is your first action? Why? Assess her pain level using the pain
scale. Check vitals and check a paradoxical pulse, if there is narrowing it could be cardiac
tamponade and I would have to contact the cardiac doctor. I would help the patient into a

comfortable position or high fowlers position if the patient is having difficulty breathing
or chest pains.
14. Ms Kit has a large dry stool, she stated that it was difficult to pass; you were also made
aware by the tech that she voided 500ml in the bedpan? What would you do with this
information? Check the color of the yellow and any present of blood. I would check the
medication list and ask the doctor if the patient can get a stool softener. Chart the
information into the patients chart.
15. You check Ms Kits monitor strip and notice the strip shown below, what is your first
action? Explain. This strip is Unifocal PVCs. I would check the patients blood pressure
and mean arterial pressure. If the patients systolic pressure is above 100 mm Hg and
MAP above 60 mm HG indicates good cardiac output. I would also check the appearance
of the patient such as appears pale, gray, or dusky and complain of chest pain or shortness
of breath, confusion, hypotension, weakness, dizziness, mental-status changes,

and

decreased urinary output. A decrease in urine output means the patient has a decreased
cardiac output. Treatment for PVC is giving the patient oxygen, treating the cause (mitral
prolapse), and giving lidocaine.

16. While preparing Ms Welbeck for the OR you heplock her IV at 1400 and noticed that she
has a pierced naval and multiple earrings in her ear lobe and her tongue is pierced and
there is a gold colored stud in place, she refuses to remove any of her jewelry, what
would you say to her? I would explain to the patient that having the piercing while

undergoing surgery would increase infection, electrical burns, and trauma and airway
obstructions. If the patient still refuses to take out the jewelry I would contact the doctor
and document that the patient refuses to remove the jewelry.

17. After returning from the OR at 1700 Ms Welbecks pulse ox is 92% on 2l nc, Lactated
Ringers infusing at 125ml hr. What action do you take? I would sit the patient up and see
if the pulse o2 will change. If it doesnt change Ill increase the oxygen liter to 4, then
come back to check on the patient in 15-30 minutes to see if there any changes in the
oxygen saturation. If there is no change I will contact the doctor.
18. Ms Welbecks significant other is visiting and asking for information on how the surgery
went, what is your response? I would look into the chart and see if the significant other is
authorized to receive information on the patient. If the significant other is not listed I
would explain why I cant give him/her information. It would be a violation of HIPPA
and patient information.
19. You receive a stat order for Clonidine 0.2mg for Ms Kit, what is your first action? I
would double-check the orders and then call the physician to voice my concern about
giving a patient this medication. Its a contraindicated in patients with heart dysrhythmias
and coronary artery disease. If the doctor still wants the patient to receive the medication
I would take a blood pressure, before administering the medication.
20. After assessing Ms. Welbecks surgical site, you notice a small amount of bloody
drainage from the site (a dime size area), the tech informed you that she voided 400ml in
the bed pan, you assess her pain level and it is 8/10 what nursing actions would you take?
I would address her pain and then administer medication. I would change the dressing

and document the small amount of bloody drainage. I would also document that she
voided in the bed pan.
21. Ms Kits monitor strip is now showing the following, what should you do? What
medications should be given? The strip is A-fib. I would assess the patient, give oxygen,
start an IV if its not established and hang NS, notify the MD then prepare for
cardioversion.

The medication I would give the patient would be digoxin, beta-

adrenergic blockers, calcium channel blocks and antithrombotic.

22. It is now the end of your shift 1900, you complete your Intake and Output
documentation for each client based on clinical findings and the following:
Ms. Kit lunch: 4oz cranberry juice, 6oz water, 4oz soup, 1 baked chicken breast, 1 cup
string beans, 1 slice whole wheat bread, 1 pat of butter.
Ms Kit dinner: 1 (12oz) can gingerale, 1 cup rice pilaf, 4oz sliced turkey breast.
IV intake: ___431.25___________ml
PO intake: _________780____ Output:
____500ml____
Ms. Welbeck dinner: 4oz apple juice, 2oz chicken broth.
IV intake: _____250________ml
PO intake: __180___________ Output:
____400_____
Your clinical day has ended. Please submit this simulated experience by the date
indicated. You will need to achieve a grade of 85 for this exercise to count as a clinical

make-up day. If you fail this exercise another will be forwarded to you which must be
submitted prior to the next clinical day. This exercise is a requirement for meeting the
expected clinical hours per New Jersey State regulatory body.