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

SITUATION I

 

Question 1:

R: Where is the pain exactly located and does it radiate anywhere?

S: On a scale of 0-10 how would you rate your pain? Signs and symptoms associated with the pain: fatigue? Nausea? Vomiting?

P: Palliate: Is there anything that helps the pain?

 

Refused answers that are already given:

P: Provoke: What provoked your pain? - when the patient went to the bathroom

Q: Quality of pain: tightness, sharp, burning? Description of the pain? - crushing

T: When/at what time did the pain start? How long did it last? - just started at 20:00

 

Question 2:

1. Diaphoresis

2. Dyspnea (SOB)

3. Pale skin

4. Peripheral cyanosis to lips and nails

 

Question 3:

1. Position the patient in fowler’s position

2. Administer oxygen

3. Do an ECG

4. Administer Nitroglycerine sublingual    

5. Let her rest and reassure her                                                                                    

6. Encourage to do pursed-lip breathing

 

Question 4:

Vasodilatory effect or side-effect of Nitroglycerine. Give the acetaminophen (Tylenol) 325 mg.

 

Question 5:

To confirm the diagnosis of myocardial infarction.

 

Question 6:

1. A nitroglycerin patch should be applied to a nonhairy area for the best and most consistent absorption rates.

2. Sites should be rotated to prevent skin irritation.

 

Question 7:

The drug should be continued if a headache occurs, as tolerance will develop. 

 

SITUATION II

 

Question 1:

Furosemide (Lasix) can be infused via intravenous push at the rate of 20 mg/min. Furosemide is a diuretic and will decrease fluid in alveoli, and assessing lung sounds can help to determine the therapeutic effect. Blood pressure should decrease with the administration of a diuretic. It is appropriate to monitor before and after administration. It is appropriate to monitor intake and output for a client receiving a diuretic.

 

SITUATION III

 

Question 1:

Nitroglycerin, as a vasodilator, causes a decrease in blood pressure. Because it is short-acting, decreasing the infusion rate will allow the blood pressure to rise. 

 

SITUATION IV

 

Question 1:

The patient coughs often during the visit.

 

Question 2:

Potassium

 

SITUATION V

 

Question 1:

• LPN = #1 administering nitroglycerine and appropriate patient monitoring for therapeutic and adverse effects are included in their scope of practice.

• PAB = #2 Monitoring pulse and O2 saturation should be delegated to the PAB.

• #3 and #4 Patient TEACHING requires RN-level education scope and practice.

 

SITUATION VI

 

Question 1:

The possibility of becoming pregnant or planning of pregnancy. It can cause fetal abnormalities or malformations or defects.

 

SITUATION VII

 

Question 1:

Elevate the head of the bed (Fowler's position) to enhance ventilation.

 

SITUATION VIII

 

Question 1:

1. Assess peripheral pulses and neurovascular status q15, q30, then hourly for 4hours/until d/c

2. Maintain bed rest as ordered – 6 hours (head of bed maybe raise 30 degrees)

3. Keep pressure dressing, sand bag or ice pack over the arterial access site.

4. Instruct patient to avoid flexing or hyperextending the affected extremity for 12-24 hours.

 

SITUATION IX

 

Question 1:

3-5 days to reach a therapeutic concentration of Coumadin

 

Question 2:

1. Use electric razor

2. Use soft-bristle toothbrush

 

SITUATION X

 

Question 1:

1. Jugular vein distension

2. Crackles

3. Weight gain of 1kg in a day

4. Hepatomegaly

5. Pink or frothy sputum

6. Orthopnea

7. Psychomotor agitation

 

Question 2:

No, the patient pulse is 59 beats per minute

 

SITUATION XI

 

Question 1:

1. Take the pulse before each dose of digoxin.

2. Do not take the dose if the pulse is less than 60 bpm, notify MD.

3. Take missed dose only up to 12 hours later.

4. Notify MD for S/S of digitalis toxicity (fatigue, weakness etc…).

5. Do not take it with antacids, laxative and cold/cough medications.

6. Take it at the same time of the day.

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Question 2:

1. Do not shake the Nitroglycerin spray

2. Do not inhale the spray

3. Hold the spray vertically by holding the device as close as possible to the mouth

4. Spray underneath the tongue

5. Do not swallow saliva

 

SITUATION XII

 

Accurately weigh the patient, and report and record the readings.

 

SITUATION XIII

 

Elevating extremities promotes venous return and reduces peripheral edema.