Situation 1

 62 y.o., has indigestion problems, experiences chest pain on exertion

 Schedules for cardiac catheterization and angiogram to assess coronary arteries

Question 1
Chest pain is mild now, NTG was given (sublingual). After the 3rd dose, pain is still mild. What nursing actions
must you do?

Answer
1) ECG
2) PQRST
3) Vital signs
4) Warn MD
5) O2 adminstration
6) Bed rest

Question 2
Pain feels like pressure/tightness in his chest. What is PQRST?

Answer
P: provoke/palliate
Q: quality
R: radiation (location)
S: severity
T: time

Question 3
Patient placed on morphine sulphate IV 5-10mg q1-2hr PRN for pain. What should you monitor for (undesired
effects of morphine)?

Answer
1) Allergic reaction (pruritus)
2) Resp depression, sedation
3) Constipation
4) Hypotension (vaso dilating effect)
5) Pupil (pinpoint)

Question 4
Serial cardiac enzymes tests were performed and confirmed that patient has an acute MI. name the 3 serum
markers to confirm an acute MI.

Answer
1) CPKMB
2) Trops
3) Myoglobin

Question 5
Primary focus of an MI treatment is to decrease oxygen expenditure and to increase oxygen concentration in
cardiac muscles. Provide 3 drug classes that can help

Answer
1) Beta blockers
2) Vasodilators
3) Calcium channel blockers
4) Opiods
5) Ace inhibitors
6) Alpha blockers

Question 6
RN auscultates and hears crackles bilaterally. MD aware. Now, we know patient has heart failure (officially
diagnosed). What 2 drugs are considered main treatment of HF?

Answer
1) Lasix (diuretics)
2) Digoxin (digitalis)

Question 7
Patient is going home. Teach which med is important to prevent recurrence of chest pain when doing ADL.

Answer
Prophylactic NTG

Situation 2
 Chief complaint: 20 y.o. male, has severe 2nd and 3rd degree burns following a motor vehicle accident
 History: was admitted to ER after car accident. In ER, he’s unconscious, 2 nd degree burns cover 5% of body
and 3rd degree burns cover 15% of body – both covering thoracic and abdo regions and right elbow
 VS:
o BP = 55/35
o HR = 210
o RR = 40
 Deteriorating from circulatory failure, 2 IVs inserted and fluids being administered
 Was finally stabilized and sent to acute med surg unit

Question 1
Burn assessment  when assessing patient fluid status, which lab findings are expected to be observed on this
particular patient (he’s a burn patient)

Answer
1) Hyperkalemia
2) Hyponatremia
3) ↑ hematocrit (dehydration)
4) ↑ serum osmolality
5) ↑ creat, ↑ BUN

Question 2
What compensatory mechanism did RN observe in patient’s VS?

Answer
1) Tachycardia
2) Tachypnea

Question 3
K+ [5.9] meq/L and hematocrit=50%. What rationale supports the lab data?

Answer
Hypovelemia (explains ht) and shifting of electrolytes (explains potassium)
Question 4
Following labs, what treatments are expected to be given and provide rationale

Answer
1) IV hydration (fluid replacement) – lactate ringers (isotonic + avoids met acidosis)
2) Treating hyperkalemia
3) Insulin (transports potassium back to cell)

Question 5
Provide 4 symptoms of uncompensated hypovolemic shock

Answer
1) ↓ BP
2) ↓ urinary output
3) ↓ RR
4) Weak thread pulse
5) Delayed cap refill
6) Altered level of consciousness
7) Change in mental status
8) Pallor (not cyanotic)

Question 6
Other than anxiety, what could explain change in patient’s behaviour?

Answer
Hypoperfusion to the brain

Situation 3
 10 y.o. female with asthma presented with tachypnea and acute SOB with audible wheezing. Before transport
to ER, took prescribed meds of cromolyn sodium and ventolin with no relief of symptoms
 She’s using accessory muscles, is tachypneic, SOB, spO2 =93% on RA.
 O2 given via mask then VS were:
o HR = 110
o RR = 40
 Auscultation: ↓AE bilaterally and inspiratory and expiratory wheezing heard + she’s coughing white sputum
 RN called MD asap, MD ordered arterial blood gas, results:
o pH= 7.5
o PaCO2 = 75
 MD ordered aerosol treatment ventolin 0.5 cc with 3.0 NS in nebulizer for 10 min stat
 20 minutes, ventolin treatment done again, showed much improvements
 Peak flow = 230/360, auscultation = clear breath sounds, and now VS are:
o HR = 108
o RR = 24
o (i.e. symptoms resolved in 30 minutes)
 RN talks to parents and finds out that playing with cat at home triggered attack

Question 1
What are 3 emergency meds for asthma attack?

Answer
1) Oxygen
2) Bronchodilators (ventolin)
3) Epinephrine

Question 2
Blood gas show pH= 7.5, what factor can be attributed to this lab finding?

Answer
Resp alkalosis

Question 3
Apart from cat, what can trigger asthma attack?

Answer
1) Dust
2) Exercise
3) Food
4) Stress, anxiety
5) Smoking
6) Cold weather
7) Smoking
8) Mold

Question 4
Why was flovent ordered during asthma attack?

Answer
For longer term management of asthma attack, ↓ swelling, ↓ production of sputum

Question 5
Patient’s mom concerned about her smoking habits (thinks may trigger daughter’s attacks). What response is most
helpful in assisting mom to promote healthier home environment?

Answer
Maintain smoke free enviro at home (solutions to this)

Situation 4
 34 y.o. African American female
 This is her 2nd pregnancy (1 live birth, no abortion). She’s at a clinic for prenatal care at 6 weeks gestation, her
weight is 198 lbs, BP=136/82
 Past mHx: SVD of 9lbs, 5oz male infant at 40 weeks gestation 8 years ago in Kenya
o Patient’s mother (bb’s grandma) had DM2
 Patient at risk for GDM (gestational diabetes). She’s over 30 years old, obese, has 1 st degree relative with type
2 diabetes
 Patient blood glucose result = 9 mmol/L, fasting blood glucose = 8mmol/L
o MD established GDM diagnosis
 Patient started on 20 units of NPH and 10 units of regular insulin with a sliding scale

Question 1
Patient wants to know if she can take pills instead for GDM. What do you tell her?

Answer
They are teratogens (oral hypoglycemic agents)
Question 2
Folic acid is prescribed. Why?

Answer
To avoid neural tube defect (spinal bifida), issues in utero, and to promote RBC production

Question 3
At 37 weeks, foetus growing fine (wt= 8 lbs, 10 oz). at 39 weeks, mom admitted to hospital for a SVD. A test with
nitrazine paper indicates that the fluid from patient’s vagina is alkaline. Provide 2 important nursing care for
ruptured membranes

Answer
1) Bedrest
2) Monitor fetal heart rate for fetal distress
3) Mom prone to infection, therefore, decrease vaginal inspection

Question 4
While in labour, which position is encouraged to prevent vena cava syndrome?

Answer
Towards left side (lateral)

Question 5
A few hours after delivery, what care should be provided

Answer
Fundus check (bubble)

Question 6
Fundus is slightly above umbilicus (I/U) and displaced to the right side, what should you do?

Answer
Offer bedpan to urinate (urinary retention), urge her to urinate

Question 7
2 indications that in question 6, interventions were effective

Answer
1) Fundus is now midline
2) Voided appropriate amount of urine

Question 8
Patient wants to breastfeed, but is frustrated because bb not latching properly. How to improve latching?

Answer
1) Position
2) Place thumb over nipple so bb nose touches
3) Rooting reflex (stroke cheek towards breast)
4) Lightly compress breast to give breast a shape resembling bb’s mouth

Question 9
On 3rd day post delivery, patient has tender breasts. Identify what is happening to patient and provide 3 ways to
relieve tenderness
Answer
Boobs are engorged:
1) Warm compress (if mom is breastfeeding, if not then cold)
2) Support breasts (breast binders)
3) Increase bb feeding or try to manually express milk to empty breasts

Situation 5
 48 year old female, has lower abdo pain (xray shows free air). Was taking Tylenol #3 for abdo and feet pain,
which lead to constipation
 Pmhx: poor vision in both eyes, IDDM (since age 8), failing cadaveric kidney (renal transplant in ’88, skin
cancer, HTN, ↑ cholesterol, CAD, MI in ’98, PVD bilateral feet ulcer, UTIs, in 2001 got a right forearm fistula
(but now can’t use it anymore due to uncontrolled HTN).
 Today, upon examination, due to intestinal obstruction (caused by Tylenol), went for resection of sigmoid and a
temporary colostomy was put in

Question 1
Blood sugar went up on admission, and now has DKA (diabetes keto acidosis). How do we treat it?

Answer
1) Sodium bicarb (to correct acidosis)
2) Regular insulin
3) Fluid restriction

Question 2
What are the immediate dangers of DKA?

Answer
1) Dehydration (hypovolemic shock)
2) Coma
3) Cardiac arrest (due to increase potassium, hyperkalemia)

Question 3
What findings RN documents as manifestations of DKA

Answer
1) Kussmal breathing
2) Fruity breath (ketone breath)
3) Ketone in urine
4) Polyuria, polydipsia
5) Met. Acidosis
6) Coma
7) Hyperkalemia

Question 4
What lab results expected to be seen for DKA

Answer
1) Met. Acidosis
2) Hyperkalemia
3) ↑ blood sugar
Question 5
Now DKA is resolver, patient is placed on insulin subQ (regular and NPH). When mixing 2 insulin in 1 syringe,
what techniques should be used?

Answer
Start with regular, and then NPH

Situation 6
 40 year old female, partial thickness burn injuries on both hands (following incident where she tipped over pot
with boiling water). Burns were washed and treated with silver sulfadiazine cream and encased in plastic bags.
Both hands were elevated and she was given IV morphine for pain
 Now admitted to the med unit, patient agitated and restless. She’s talking rapidly and non stop
 VS:
o HR=110
o To=37.5
o RR=24
o BP=150/100
 Patient is mildly diaphoretic and patient complaining feeling hot (she broke up with partner and has lost weight
since then). MD made aware, dx  grave’s disease. Urgent thyroid test are ordered to confirm dx. Started on
propanol 40 mg. Treatment focused now on hyperthyroidism, not burn.

Question 1
What 3 lab tests are done to confirm hyperthyroidism

Answer
1) TSH
2) T3
3) T4

Question 2
While performing routine post op assessment, RN notes VS changed. Thyroid storm suspected. What changes does
RN report to surgeon?

Answer
1) Uncontrolled fever
2) Tachycardia
3) Tachypnea
4) HTN
5) Anxiety
6) Resp distress
7) Diarrhea
8) Coma

Question 3
When recovered from anaesthesia. RN asks simple questions, yet seems to be irrelevant to the patient. What is RN
trying to accomplish?

Answer
Look for whispery voice, then hoarseness
Question 4
To check if some parathyroid glands were accidently resected during surgery, RN should perform which test?

Answer
1) Chvostek’s sign
2) Trousseau sign

Question 5
Immediately following thyroidectomy, RN ensures that _______ and ________ are available at bedside. (fill in the
empty lines)

Answer
1) Oxygen and trach set up
2) Calcium gluconate

Situation 7
 A 30 year old black male consults the clinic physician because of cough, sputum production and mild
hemoptysis. He has had evening rise of temperature for the past month and claims to have lost 30 lbs over a
three month period. On exam he appeared to be chronically ill and wasted. Wheezing and crackles were noted
over the right lung. CXR shows fluffy infiltrates and some amount of contraction of the right upper lobe. There
is a cavity in the superior segment of the right upper lobe. A working diagnosis of TB is made. Sputum is
positive for AFB. The patient was started on INH, rifampin, pyrazinamide, and ethambutol.
 He has a 33 year old wife, 5 year old daughter, 85 year old father and 82 year old mother. They all reside in the
same household. His son is 15 years old and is living in Texas for the past 2 years.

Question 1
The patient asks the nurse why he is taking multiple TB drugs. What rationale would the nurse provide the patient?

Answer
Reduce possibility of drug resistance

Question 2
Provide 4 drugs that are prescribed during the initial TB treatment

Answer
INH, rifampin, pyrazinamide, ethambutol

Question 3
Patient was placed on resp isolation, and has been taking TB meds for a week. The patient asks the nurse “how
long do I have to stay isolated feel like a prisoner”/ what will the nurse answer?

Answer
After 2 weeks of strict complicate to drug therapy, he may be out of isolation

Question 4
Patient’s skin is yellow and his sclera is yellow. Which TB med is responsible for this finding and why?

Answer
INH (hepatic toxicity)

Question 5
After 2 weeks of taking TB meds, the patient came off isolation. He continues multiple drug therapy. What findings
should indicate that patient’s meds regimen is effective?
Answer
CXR, 3 sputum cultures are negative, ↓ cough, ↓ fever

Situation 10
 Ashley is a 16 y.o. high school student. Today, she couldn’t attend her afternoon classes and went home early
due to headache, body ache and pain. She thought she had caught the flu. By the next morning, Ashley’s
temperature has soared to 39.4oC and her throat felt like a burning fire. Even worse, she was so tired she could
hardly lift her head off the pillow. Ashley has never felt this bad with any cold/flu. Ashley’s mom took her to
the doctor, where a physical examination and blood test revealed that she had mononucleosis.

Question 1
What information must the nurse give to Ashley when asked about the causative agent of mono?

Answer
EBV

Question 2
When providing care for Ashley, the nursing staff should remember to implement which of the following
precautionary measures? Provide 2 protective barriers

Answer
1) Mask
2) Gloves
3) Gown
4) (i.e. contact precautions)

Question 3
What discharge teaching given to Ashley is critically important? Provide, your rationale.

Answer
1) Proper hand washing
2) No contact sports or heavy lifting (rupture of spleen)

Situation 11
 3 year old girl presents with 2 day history of low grade fever and vomiting. Diarrhea started this morning.
Admission assessment mild to mod abdo tenderness upon palpitation, urine output for last 2 hrs very scanty.
MD wants CBC and throat culture, IV infusion to start broad spectrum IV abx

Question 1
IV in place on left cephalic vein and NS infusing. Will you apply splint on left hand and why

Answer
Yes, to stabilize the arm, keep IV in place

Question 2
Diarrhea continues and bloody stools MD orders more blood tests and PRBC (1 unit). Within 2 minutes of giving
PRBC, pt has chills and fever. Transfusion d/c by MD. What do you do with remaining blood?

Answer
Return it to blood bank to investigate why there was a rxn

Question 3
MD ordered NGT. Select proper size and length. How do you calculate appropriate size?

Answer
From nose to ear lobe to the xiphoid process

Question 4
Pt NPO for 2 days now. CVAD inserted for TPN. On 2nd day of TPN, the bag has leaks. What do you do?

Answer
1) Stop it
2) Replace with D10 or D20 (hypertonic solution)
3) Inform MD

Situation 13
 52 year old fire fighter  dyspnea on exertion. 2 months of nocturnal cough, a 10lbs wt loss, fatigue. Denies
smoking, drinks 2 to 3 six packs of beer daily on weekends.
 ↓ breath sounds 1/3 of way up, right side crackles, JVP, hepatojugular reflux, +2 pitting edema on knees
 Dx = acute heart failure

Question 1
Reports that he becomes SOB walking up stairs, toileting, ADLs. Develop dx for patient.

Answer
Activity intolerance related to decreased oxygenation

Question 2
On the 4th day of his hospital stay, the patient reports nausea, vomiting, abdo cramps and halo vision. What lab
value would the nurse analyze and why?

Answer
1) Digoxin levels
2) Potassium levels

Question 3
The patient became unstable and he went into cardiac arrest. CPR was performed and epinephrine given via ET
tube. Following a successful resuscitation from a pulseless dysrhythmia, which of the following assessment is
critical for the nurse to include in the plan of care? Provide one plan of care

Answer
Check pulses, urinary output
Epinephrine is a drug that will increase HR and promote blood vessel contractions