RN101
Home of the Registered Nurses (RN) and
Licensed Practical Nurses (LPN)

 SITUATION I

Mrs. A, a 50-year-old woman with a history of type I diabetes mellitus and angina was hospitalized this morning after experiencing retrosternal chest pain that began after eating a heavy meal. Pain is now present but is minimal. Vital signs are: BP-110/80, P-80/min, R-19, T-98˚F, and O2 sat. 97% in R/A.

 

At 20:00, while lying in her bed, Mrs. A tells you, “I'm having a crushing chest pain that just started when I went to the bathroom." Her vital signs are: BP-127/89, P-89/min irreg., R- 12, T-98.5˚F, and O2 sat. is 89% in R/A.see answer

 

Medical Orders

Glimepiride 1 mg QD

Metformin 500 mg BID

Acetaminophen (Tylenol 325 mg 1-2 tabs PO q 3-4h PRN for pain

IF RETROSTERNAL PAIN:

ECG STAT

O2 3L/min via nasal prongs

Nitroglycerine sublingual spray q5 min x3

​

Question 1:

Name 2 additional important questions you must add to complete your assessment?

1. _____________________________________________________________________________________________________________________________.

2. _____________________________________________________________________________________________________________________________.

 

Question 2:

Based on the clinical problem above, what other possible objective data that the patient may present? Identify two.

1. _____________________________________________________________________________________________________________________________.

2. _____________________________________________________________________________________________________________________________.

 

Question 3:

Identify three (3) interventions you must carry out immediately according to the situation?

1. _____________________________________________________________________________________________________________________________.

2. _____________________________________________________________________________________________________________________________.

3. _____________________________________________________________________________________________________________________________.

 

After all your interventions, the patient is now stable and her vital signs are all normal but she is complaining of dizziness, flushing, and headache. She rates her headache as 3/10 on the pain scale.

 

Question 4:

1. _____________________________________________________________________________________________________________________________.

 

The physician ordered a blood test for Cardiac-Biomarkers (CK-MB, Troponin, and LDH).

 

Question 5:

What is the main purpose of this test?

1. _____________________________________________________________________________________________________________________________.

 

Mrs. A is to be discharged home today with a transdermal nitroglycerin patch.

 

Question 6:

What instructions will you include in the patient's teaching plan regarding her patch?

1. _____________________________________________________________________________________________________________________________.

2. _____________________________________________________________________________________________________________________________.

 

Question 7:

After a few days of using her nitroglycerin patch, she complains that she having a headache from time to time and asks you if she can remove the patch for a few hours whenever she has a headache. Yes or No? Justify.

1. _____________________________________________________________________________________________________________________________.

 

SITUATION II

A patient with Congestive Heart Failure is ordered furosemide (Lasix) to be given via intravenous push.see answer

 

Question 1:

Apart from administering the medication slowly, identify three other interventions should you perform regarding the patient's medication?

1. _____________________________________________________________________________________________________________________________.

2. _____________________________________________________________________________________________________________________________.

3. _____________________________________________________________________________________________________________________________.

 

SITUATION III

A patient receiving intravenous nitroglycerin at 20 mcg/min complains of dizziness. Nursing assessment reveals a blood pressure of 85/40 mmHg, heart rate of 110 beats/min, and respiratory rate of 16 breaths /min.see answer

 

Question 1:

The MD prescribed to monitor the patient's vital signs every 10 minutes and decrease the intravenous nitroglycerin by 10 mcg/min. Explain briefly why the MD decided to decrease the dose?

1. _____________________________________________________________________________________________________________________________.

 

SITUATION IV

You make a home visit to evaluate a hypertensive patient who has been taking spironolactone (Aldactone) and enalapril (Vasotec) for 3 weeks. The patient complains of frequent urination, cough often during your visit. He states “I get dizzy sometimes." His latest blood pressure is 138/86 mm Hg.see answer

 

Question 1:

Which assessment information indicates that you need to contact the physician about a change in the drug therapy?

1. _____________________________________________________________________________________________________________________________.

 

Question 2:

What laboratory value will be most important for you to monitor?

1. _____________________________________________________________________________________________________________________________.

 

SITUATION V

You are working with an experienced PAB and an LPN on the telemetry unit. A patient who had an acute MI 3 days ago has activity intolerance due to fatigue and chest pain.see answer

Tasks:

1. Administering nitroglycerin (Nitrostat) if chest discomfort occurs during patient activities.

 2. Monitoring pulse and oxygen saturation before and after patient ambulation.

3. Teaching the patient energy conservation techniques to decrease myocardial oxygen demand.

4. Explaining the rationale for alternating rest periods with exercise to the patient and family.

 

Question 1:

Which task is best done by NURSE, LPN, and PAB?

 

 

 

SITUATION VI

You obtained the history and physical examination of a female patient who is receiving atorvastatin (Lipitor). She just got married and is planning a pregnancy. The patient has a family history of diabetes, glaucoma, and coronary artery disease.

see answer

Question 1:

Which of the following data you’ve obtained requires immediate attention? Why?

1. _____________________________________________________________________________________________________________________________.

 

SITUATION VII

A patient with deep vein thrombosis who is on bed rest with legs elevated experiences acute chest pain and dyspnea.

see answer

Question 1:

Before notifying the physician what is your initial intervention?

1. _____________________________________________________________________________________________________________________________.

 

SITUATION VIII

Mr. C, 57-year-old, Canadian,  has just returned from a cardiac catheterization. You are the nurse who is assigned to him. You’re planning to take his V/S q 15 mins for the first hour and to assess for bleeding at the catheterization site.see answer

​

​

Question 1:

Identify other four (4) priority interventions or teachings for the patient?

1. _____________________________________________________________________________________________________________________________.

2. _____________________________________________________________________________________________________________________________.

3. _____________________________________________________________________________________________________________________________.

4. _____________________________________________________________________________________________________________________________.

 

SITUATION IX

You brought a 5mg warfarin sodium (Coumadin) tablet as per new medical order to the patient who is currently on heparin infusion. You explain to him that it is also an anticoagulant. He asks  you,  “Why do I have to take Coumadin when I already have a heparin infusion?”see answer

 

Question 1:

What would be your reply to the patient’s question? Give the main reason:

1. _____________________________________________________________________________________________________________________________.

 

Question 2:

Today, you are doing a discharge teaching to Mr. B. Identify two important teachings for the patient regarding his hygiene care.

1. _____________________________________________________________________________________________________________________________.

2. _____________________________________________________________________________________________________________________________.

 

SITUATION  X

You are a nurse in seniors’ residence and assigned to Mrs. E who was admitted one week ago.

 

Medical History

Heart Failure

Atrial Fibrillation

Alzheimer's Disease

Medications

Digoxin (Lanoxin) 0.125 mg 1 tab qd

Ramipril (Altace) 5 mg bid 1 tab

Furosemide (Lasix) 40 mg 1 tab qd

​

 

When you enter her room, Mrs. E said that she has been feeling a little shortness of breath. You take vital signs immediately: BP 97/58, P-112/min, R-22/min, SpO2 95%. You notice that she has leg edema and her capillary refill is >3 seconds. You notify the physician immediately.see answer

 

Question 1:

Identify two(2)  other signs that will indicate a deterioration of her heart condition?

1. _____________________________________________________________________________________________________________________________.

2. _____________________________________________________________________________________________________________________________.

 

Given Mrs. E’s signs and symptoms, the dose of furosemide was increased to 80 mg qd two days ago.

 

LABORATORY RESULTS

Na: 135 mmol/L (normal: 135-145 mmol/L)

K: 4.2 mmol/L (normal: 3.5-5.0 mmol/L)

Cl: 102 mmol/L (normal: 100-106 mmol/L)

Digoxemia: 2.0 mmol/L (normal: 1.0-2.6 mmol/L)

​

Vital Signs: BP: 110/80 mmHg, R: 16/min, P: 59/min

 

 

 

Question 2:

Will you give her digoxin? Yes ⃝     No ⃝    and why:

1. _____________________________________________________________________________________________________________________________.

 

SITUATION XI

You are the nurse caring for Mr. D with Congestive Heart Failure (CHF) who is for discharge today.see answer

 

Medical Prescriptions

Lanoxin (Digoxin) 0.125 mg daily

Lasix 20 mg PO daily

Nitroglycerin spray 0.4 mg S/L x 3 q 5mins PRN

​

Question 1:

Identify two (2) guidelines that you should include when teaching the patient about his digoxin?

1. _____________________________________________________________________________________________________________________________.

2. _____________________________________________________________________________________________________________________________.

 

Before his discharge, you verify how he should administer his own Nitroglycerin spray. When he demonstrates it, he shakes the spray then sprays it into his mouth as if inhaling it.

 

Question 2:

Teach Mr. D how he should administer the Nitroglycerin spray in order to receive the optimal dose of the medication.

1. _____________________________________________________________________________________________________________________________.

2. _____________________________________________________________________________________________________________________________.

3. _____________________________________________________________________________________________________________________________.

 

SITUATION XII

Question 1:

An elderly patient is being monitored for evidence of congestive heart failure. As a nurse, what will you instruct the PAB to do during morning care to detect early signs of heart failure?see answer

1. _____________________________________________________________________________________________________________________________.

 

SITUATION XIII

You’re doing a discharge teaching to a patient with deep vein thrombosis. The patient asked you about the importance of elevating his legs.see answer

 

Question 1:

What would be your response?

1. _____________________________________________________________________________________________________________________________.

2. _____________________________________________________________________________________________________________________________.