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

SITUATION I

 

Question 1:

1. Immobility due to a history of stroke (stays in bed).

2. Poor nutritional intake due to nausea.

3. Poor fluid intake (dehydration).

4. Humidity to wound due to constant pressure to the area or urinary incontinence.

 

Question 2:

1. Maintain a moist environment.

2. Don't expose the wound to air for a long time.

3. Apply skin barrier around the wound.

4. Avoid prolong dressing change.

5. Use a warm solution (Normal Saline).

EXTRA: Increase frequency of dressing change to prevent maceration.

 

SITUATION II

 

Question 1:

1. Apply pressure ulcer mattress.

2. Use pillows to keep bony prominences apart (such as knees and ankles).

3. Maintain the head of bed at or below 30 degrees.

4. Place pillow under the calf to elevate the heel or use heel suspension boots.

 

SITUATION III

 

Question 1:

1. Fill out an incident/accident report.

2. Notify the doctor.

3. Notify the head nurse.

4. Notify the patient's family.

 

Question 2:

1. Vision problem.

2. Inadequate lighting.

3. Personal belonging/call bell are not at patient's reach.

4. Orthostatic hypotension.

5. Polypharmacy (multiple used of medications).

6. Fall history.

 

Question 3:

This syndrome is characterized by things like fear of falling again, increased immobility, loss of muscle and control, lack of sleep, nutritional deficits.

 

Question 4:

Allergy to dye/contrast media/shellfish.

 

SITUATION IV

 

Question 1:

Respiratory Alkalosis

 

Question 2:

Metabolic Alkalosis

 

Question 3:

PH is High 

PCO2 is Normal

HCO3 is High

 

SITUATION V

 

Question 1:

In iron deficiency anemia, iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in red blood cells. An oral iron supplement should be administered through a straw or medicine dropper placed at the back of the mouth because the iron stains the teeth.

 

Question 2:

The parents should be instructed to brush or wipe the child’s teeth or have the child brush the teeth after administration. Iron is administered between meals because absorption is decreased if there is food in the stomach. Iron requires an acid environment to facilitate its absorption in the duodenum. Iron is not added to formula or mixed with cereal or other food items.

 

Question 3:

No, because it will decrease iron absorption.

 

SITUATION VI

 

Question 1:

Whether the home has stairs and/or throw rugs.

 

SITUATION VII

 

Question 1:

She prefers a woman to take care of her.

 

SITUATION VIII

 

Question 1:

Notify the physician regarding the patient's situation.

 

SITUATION IX

 

Question 1:

1. Witness on disposal.

2. Double verification on dosage.

 

SITUATION X

 

Question 1:

1. The patient is endangered to hurt self and others and isolate the patient.

 

SITUATION XI

 

Question 1:

1. Lower the patient gently to the floor.

 

SITUATION XII

 

Question 1:

1. Paralytic ileus or absence of peristalsis.

 

Question 2:

1. Auscultate the patient's abdomen.

2. Percuss the patient's abdomen.

3. Palpate the patient's abdomen.

4. Ask if the patient is passing gas.

 

SITUATION XIII

 

Question 1:

Contact

 

Question 2:

Name 4 elements which should be implemented in order to prevent the spread of MRSA.

1. Wear gown and gloves when in contact with the patient.

2. Install a sign above the door that room is in isolation.

3. Provide a laundry basket for isolation use only.

4. Provide equipment inside the isolated room such as Vital Signs machine to prevent cross contamination.

5. Wash hands after leaving the room.

 

Question 3:

1. Perform a nasal swab.

2. Obtain a urine sample.

3. Obtain a sample from her stoma.

 

SITUATION XIV

 

Question 1:

Three (3) days

 

Question 2:

1. Have you passed a pregnancy test?                         

2. Do you have any allergies to medication?

3. Has the patient signed the emergency contraception form?

 

SITUATION  XV

 

Reinforce the dressing

Justification: The first dressing change is never changed by the nurse, monitor progression of bleeding. Stop hemorrhaging, prevent infection.

 

SITUATION XVI

 

Question 1:

8:00 am or 30 – 60 minutes before dressing change.

To give him optimal pain relief during the dressing change. Or serum concentration of the medication will be at its highest when the dressing is changed.

 

Question 2:

Tylenol #3 contains Codeine 30mg as well as Acetaminophen 325 m that will give him better pain relief.

 

SITUATION XVII

 

Question 1:

Respiratory rate is 10/min