Case Analysis: Ms. Ngyuen

QUESTION 1

1. Scenario 1: Ms. Ngyuen, PART 1

The nurse on the neuro step-down (transitional care) unit takes report on Ms. Kim Ngyuen, a 25-year-old female with no medical history who sustained a R subdural hematoma in a skiing accident. Ms. Ngyuen arrived by ambulance to the ED 24 hours ago and immediately went to the OR and had the hematoma removed. Her post-op CT scan shows cerebral edema. Her father is with her, they were skiing together when this happened

She has been on the neuro step-down unit for 12 hours.

Exam from 1 hour ago: Opens eyes spontaneously; oriented X 2, confused about the date; follows commands. Slight pronator drift on the left; gait is steady and she denies dizziness or weakness. Cranial nerves II-XII intact. The rest of her exam is within normal limits. She has an 18 gauge IV to her right hand and a 20 gauge IV to her left forearm, both are saline locked. She has been up to the bathroom twice and voided a total of 700 mL clear yellow over the past 12 hours. She’s tolerating clear liquids and had a total of 500 mL of fluid P.O.

Vital signs: BP 120/80; HR 72 regular; RR 12; SpO2 100% on room air; T 98.6 f oral; reports pain 5/10, headache.

• Regular diet as tolerated

• Activity as tolerated

• Physical therapy consult

• Neuro exams Q 2 hrs

• IV D5W at 125 mL/hr

• Acetaminophen 650 mg P.O. Q 6 hrs prn pain

What priority concerns does the nurse identify for Ms. Ngyuen?

The trauma this event has caused to her father and risk for disrupted family processes

The risk for elevated ICP and seizures

The risk for further bleeding and hypovolemic shock

The risk for vasospasm and secondary ischemic injury to the brain

1 points

QUESTION 2

1. Refer to Scenario 1: Ms. Ngyuen, PART 1

What provider order does the nurse question?

Physical therapy consult

D5W IV at 125 mL/hr

Regular diet

Acetaminophen 650 mg PO Q 6 hrs prn pain

1 points

QUESTION 3

1. Refer to Scenario 1: Ms. Ngyuen, PART 1

What interventions does the nurse expect to find in the plan of care for Ms. Ngyuen?

Select ALL that apply

Keep head of bed elevated at least 30 degrees

Place indwelling urinary catheter

Seizure precautions

Monitor Glasgow Coma Scale score

1 points

QUESTION 4

1. Refer to Scenario 1: Ms. Ngyuen, PART 1

PART 2

One hour later, Ms. Ngyuen’s father finds the nurse in the hallway. “My daughter’s breakfast tray arrived but she seems kind of out of it,” he says. The nurse finds Ms. Ngyuen will open her eyes to pain; offers no verbal response; and localizes with her right arm, withdraws with the left.

What action does the nurse take first?

Take Ms. Ngyuen's blood pressure and pulse

Ensure Ms. Ngyuen's head of bed is elevated and her head and neck are in good alignment

Call the rapid response team

Notify the provider

1 points

QUESTION 5

1. Refer to Scenario 1: Ms. Ngyuen, PART 1 & PART 2

What provider orders does the nurse anticipate?

Transfuse one unit of PRBCs and one unit of FFP

Prepare for central line placement and normal saline IV fluid bolus

Furosemide IV and MRI of the brain

Mannitol IV and CT scan of the brain

1 points

QUESTION 6

1. Refer to Scenario 1: Ms. Ngyuen, PART 1 & PART 2

Ms. Ngyuen has a subarachnoid bolt placed and she is transferred to the ICU. After treatment, her neuro exam returns to her post-op baseline. Her ICP is 10-15.

What risk does the nurse identify related to the subarachnoid bolt?

Overdrainage of cerebrospinal fluid

Cerebral edema

Infection

Seizures

1 points

QUESTION 7

1. Scenario 2: Mr. Tyrone Jenkins PART 1

The nurse on the neuro unit takes report from the ICU: Mr. Tyrone Jenkins is a 50-year-old male with a history of hypertension and type 2 diabetes who sustained a complete spinal cord injury at T4 one week ago in a bicycle crash. He also had a mild concussion with GCS of 13 for a few hours post event, and now has a GCS of 15. Spinal shock has resolved and Mr. Jenkins is ready to transfer from the ICU to the neuro unit. He has an indwelling urinary catheter with clear yellow urine, 1050 mL over the past 24 hrs. his last bowel movement was 4 days ago after a bisacodyl suppository and he has been tolerating a regular diet with poor appetite. The rest of his exam is within normal limits. His husband and their 2 children, a 5-year-old boy and a 10-year-old girl, are with him.

Vital signs one hour ago: BP 140/80; HR 67 regular; RR 16; SpO2 98% on room air; T 37 c oral; denies pain. On arrival to the neuro unit, Mr. Jenkins’ condition is unchanged. His daughter asks if she can stay with her dad overnight.

What is the nurse’s priority concern?

Assisting Mr. Jenkins to get out of bed to the chair

Starting Mr. Jenkins on a bowel and bladder management program

Instructing Mr. Jenkins' family on unit visiting policies

Administering Mr. Jenkins' antihypertensive medications

1 points

QUESTION 8

1. Refer to Scenario 2: Mr. Tyrone Jenkins PART 1

What risks does the nurse identify for Mr. Jenkins?

Select ALL that apply

Inadequate nutrition

Disrupted family processes

Urinary tract infection

Pressure-related skin injury

1 points

QUESTION 9

1. Refer to Scenario 2: Mr. Tyrone Jenkins PART 1

What will be the best bladder management plan for Mr. Jenkins?

Voiding using the Crede manouver

Condom catheter

Indwelling urinary catheter

Intermittent straight cath

1 points

QUESTION 10

1. Scenario 2: Mr. Tyrone Jenkins PART 1

What will Mr. Jenkins need to support his mobility?

An electric wheelchair with sip and puff controls

An electric wheelchair with hand controls

Bilateral leg braces and crutches

A manual wheelchair

1 points

QUESTION 11

1. Refer to Scenario 2: Mr. Tyrone Jenkins PART 1

What will the nurse teach Mr. Jenkins about skin care?

Select ALL that apply

The importance of good nutrition and hydration

How to inspect his skin for signs of injury

Change your position at least every 2 hours

How to protect his skin if he experiences bowel incontinence.

1 points

QUESTION 12

1. Refer to Scenario 2: Mr. Tyrone Jenkins PART 1

PART 2

The nurse removes Mr. Jenkins' urinary catheter and Mr. Jenkins eats lunch with his family. One hour later, Mr. Jenkins wakes from a nap and reports feeling hot and flushed. The nurse finds him lying flat in bed, flushed and diaphoretic.

Vital signs: BP 180/90; HR 55 regular; RR 20

What action does the nurse take next?

Raise the head of the bed

Reinsert a urinary catheter

Call the rapid response team

Turn Mr. Jenkins to his left side

1 points

QUESTION 13

1. Scenario 3: Ms. Rasheeda Williams PART 1

The nurse in the emergency department is part of the team providing care to Rasheeda Williams, a 45-year-old female who was burned when her propane barbeque exploded. She sustained burns to her chest, upper back, neck, lower face and both arms. She is coughing up black-streaked yellowish sputum and the nurse hears stridor in the upper airway on inhalation and exhalation. The skin over her chest, lower face and both arms is red and blistered with areas of black and edema throughout. Ms. Williams opens her eyes spontaneously, mumbles incomprehensibly, and follows commands. She is accompanied by several family members.

What is the nurse’s first priority?

Escorting Ms. Williams' family to the family waiting area

Starting an IV and administering a fluid bolus

Assisting to administer albuterol via nebulizer treatment

Assisting the team in placing an endotracheal tube for airway management

1 points

QUESTION 14

1. Refer to Scenario 3: Ms. Rasheeda Williams PART 1

PART 2

Within 45 minutes of arrival, Ms. Williams is intubated and connected to a mechanical ventilator. She has a central line placed in the left femoral vein and is started on Ringer’s Lactate IV at 250 mL/hr. She received sedation and analgesia and is now unresponsive. Her family is in the family waiting area and has been updated on her condition.

Vital signs: BP 110/70; 110 sinus tachycardia; RR 20; SpO2 100%; T 96 f rectal

Weight: 55 kg; Height: 5’5”

The team estimates Ms. Williams’ has deep partial-thickness and full thickness burns over 30% of her total body surface area. She is transferred to the burn unit with a provider order to apply silver sulfadiazine 1% cream (Silvadene) to her wounds and cover with dry gauze.

What risks does the nurse identify for Ms. Williams and her family?

Select ALL that apply

Electrolyte imbalances

Post-traumatic stress disorder

Hypovolemic shock

Hyperthermia

1 points

QUESTION 15

1. Refer to Scenario 3: Ms. Rasheeda Williams PART 1 & PART 2

How much total IV fluid does the nurse anticipate giving Ms. Williams over the first 24 hours after her injury?

3.5 - 6.5 liters

6 liters

At least 10 liters

8.5-12 liters

1 points

QUESTION 16

1. Refer to Scenario 3: Ms. Rasheeda Williams PART 1 & PART 2

What are the expected therapeutic effects of silver sulfadiazine 1% cream?

Debriding the wound bed and preparing it for skin grafting

Keeping the wounds moist and preventing infection

Accelerating skin regrowth and preventing infection

Preventing scars and contractures

1 points

QUESTION 17

1. Refer to Scenario 3: Ms. Rasheeda Williams PART 1 & PART 2

Five days later, Ms. Williams is extubated and the nurse prepares her for hydrotherapy wound debridement. Ms. Williams asks the nurse what to expect during this procedure.

What is the nurse’s priority concern?

Making sure Ms. Williams' wounds are covered to prevent them from getting wet during the procedure

Providing adequate pain management before, during and after the procedure

Reassuring Ms. Williams that the procedure is no different from taking a bath at home

Avoiding Ms. Williams' questions about the procedure in order not to cause increased anxiety

1 points

QUESTION 18

1. Refer to Scenario 3: Ms. Rasheeda Williams PART 1 & PART 2

Over the next 2 weeks, Ms. Williams’ wounds are debrided several times and begin healing. One week after receiving skin grafts to her chest, arms and hands, she is fitted for compression garments. Ms. Williams asks the nurse what these are for.

What is the nurse’s best response?

"The compression garments are optional, you don't have to wear them if you don't want to."

"The compression garments will flatten your scars and improve your healing."

"The compression garments are used to keep the skin grafts in place."

"You'll only have to wear the compression garments while you sleep."

1 points

QUESTION 19

1. Scenario 4: Mr. Cadmael Ketz PART 1

The nurse in the medical unit receives shift handoff report on Mr. Cadmael Ketz, an 65-year-old male with stage IV prostate cancer with metastasis to bone and lung who has decided not to pursue further curative therapies. He had palliative surgery yesterday to place a suprapubic urinary catheter. He is awake and oriented X3, reports feeling weak and fatigued. Pain has been his most distressing symptom, he rates his pain at 10/10 at its worst, 3/10 at its best. He’s also short of breath and has little appetite. He has a large family with his wife, 4 sons and several grandchildren.

Vital signs: BP 100/70; HR 88 regular; RR 16; SpO2 94% on room air; T 37 c oral; pain 5/10

He has made 12 attempts with the PCA and received 2 injections over the past hour.

Provider orders

 Do not attempt resuscitation

 Comfort care

 PCA dilaudid

o Basal: 0.2 mg/min

o Injection: 0.4 mg

o Lockout: 6 minutes

o Maximum: 1 mg/hr

 Docusate sodium 100 mg PO BID

 Bisacodyl suppository 1 daily prn no BM

 Oxygen 2 liters nasal cannula prn

 Regular diet as tolerated

 Activity as tolerated

What is the nurse’s priority concern in the care of Mr. Ketz?

Determining what food he would like to eat

Managing his pain

Making sure his family is comfortable

Improving his oxygenation

1 points

QUESTION 20

1. Refer to Scenario 4: Mr. Cadmael Ketz PART 1

What action will the nurse take first to improve Mr. Ketz' pain management?

Ask the provider to increase the injection dose of dilaudid

Ask the provider to increase the basal dose of dilaudid

Explore Mr. Ketz' understanding of how to use the PCA

Assist Mr. Ketz to get up our of bed to a chair

1 points

QUESTION 21

1. Refer to Scenario 4: Mr. Cadmael Ketz PART 1

What action will the nurse take to improve Mr. Ketz' dyspnea?

Select ALL that apply

Hold pain medications

Administer oxygen 2 liters via nasal cannula

Apply a cool, wet washcloth to his face

Raise his head of bed

1 points

QUESTION 22

1. Refer to Scenario 4: Mr. Cadmael Ketz PART 1

PART 2

Mr. Ketz is transferred to an in-patient hospice facility for comfort care. Over the next two weeks, Mr. Ketz stops eating, is unable to get out of bed, and becomes less and less responsive. The hospice nurse now finds he does not open his eyes to voice, is verbally unresponsive and lies rigid in bed. His wife reports Mr. Ketz grimaces and moans when she tries to move him. He is no longer able to swallow.

Vital signs: HR 65 regular; RR 12 regular

Medications

 Methadone 60 mg PO BID

 Morphine 30 mg PO prn breakthrough pain

What action does the nurse take first?



Request a consultation with the speech therapist

Provide range of motion exercises to Mr. Ketz' extremities

Ask the provider to discontinue the methadone and morphine

Ask the provider to change Mr. Ketz pain medication from PO to SQ or IV

1 points

QUESTION 23

1. Refer to Scenario 4: Mr. Cadmael Ketz PART 1 & PART 2

Mr. Ketz’ breathing is now irregular with brief periods of apnea and he is making gurgling sounds in his throat as he breaths. His wife is with him, the rest of his family is in the family lounge down the hall.

Vital signs: HR 45; RR 8

How does the nurse respond to these changes in Mr. Ketz condition?

Connect Mr. Ketz to the cardiac monitor

Administer naloxone IV

Ask his wife to join the family in the family lounge while you suction Mr. Ketz' oropharynx

Administer an anticholinergic medication and let the family know they should stay with him

1 points

QUESTION 24

1. Scenarion 5: Ms. Jeannie Geary PART 1

The nurse on the orthopedic surgery unit takes shift hand-off report on Ms. Jeannie Geary, a 37-year-old female with no significant medical history who was in an automobile crash. She sustained a fracture to her left femur shaft, fractures to 3 ribs on the left and a pneumo-hemothorax s. She is awake and oriented X 3. She has balanced suspension skeletal traction to her left leg, and a chest tube to the left lower chest to suction that has drained 75 mL of serosanguinous fluid over the past 12 hour. She reports pain in her left leg and chest

Vital signs: BP 120/80; HR 75 regular; RR 12; SpO2 100% on room air; T 37 c oral; pain 4/10, tolerable.

What assessments does the nurse include related to Ms. Geary’s fracture?

Select ALL that apply



Position of the weight

Condition of the pin sites

Circulation, movement and sensation to the left toes

Skin integrity under the left leg splint

1 points

QUESTION 25

1. Refer to Scenarion 5: Ms. Jeannie Geary PART 1

What assessments does the nurse look for to determine proper function of Ms. Geary’s chest tube and drainage system?

Select ALL that apply

Presence of tidaling in the tubing and water seal chamber

Presence of intermittent air bubbles in the water seal chamber

Chest tube insertion site is open to air

Presence of continuous bubbling in the collection chamber

1 points

QUESTION 26

1. Refer to Scenarion 5: Ms. Jeannie Geary PART 1

PART 2

An hour later, Ms. Geary reports a new sharp, stabbing pain in her right chest and she is anxious and short of breath with RR of 32 and SpO2 of 89%. Lung sounds are clear.

What action does the nurse take related to this change in Ms. Geary’s condition?

Call the provider and the rapid response team

Look for a blockage in the chest tube

Administer pain medication

Administer anti-anxiety medication

1 points

QUESTION 27

1. Refer to Scenarion 5: Ms. Jeannie Geary PART 1 & PART 2

What new provider orders does the nurse anticipate?

Replacement of the chest tube

Endotracheal intubation

Anticoagulant medications

A diuretic