Scenario 1 (Total 15 marks)
You are a new graduate registered nurse working in a small local hospital emergency department.
Mr Gary MacDonald is a 52- year-old businessman. McDonald has a very stressful position, and as a coping mechanism he drinks quite heavily. Mr McDonald has been feeling increasingly unwell lately but has been too busy to go to the doctor for a check-up. His abdominal girth has increased, his ankles are a bit swollen and he gets short of breath on exertion.
Mr McDonald was attending a business meeting when he began to vomit quite a lot of bright red blood.
On arrival at the Emergency Department of the local hospital he has a vomit bag with about 350 mL of bright red blood. He is pale and complaining of feeling dizzy and appears confused as to what is happening to him and where he is. His immediate vital signs are:
Blood pressure 80/50mmHg, Pulse 130bpm, Respiratory rate 28, Oxygen saturation 91% on room air, Temperature 36.1 Celsius, Glasgow Coma Score (GCS) 13.
Question 1: Maximum word limit 100 words. (2 mark) (Reference not required for this question)
Based on your A-G assessment identify two (2) areas that are your highest priorities and express then as Nursing Diagnoses with “Related to” and “Evidenced by” statements.
Question 2: Maximum word limit 150 words. (4 marks)
The doctor makes an initial medical diagnosis of bleeding oesophageal varices due to alcoholic cirrhosis. Explain the pathophysiology that caused his bleeding oesophageal varices.
Question 3: Maximum word limit 200 words. (4 marks)
Based on Mr McDonald’s current condition, and NSW Health SAGO chart and DETECT policy requirements, outline four immediate nursing actions and their rationales within your scope of practice (as RN new graduate).
Question 4: Maximum word limit 150 words. (3 marks)
Briefly discuss the current best medical practice recommendations for the treatment of bleeding oesophageal varices including likely intravenous fluids, medications, and procedures.
Question 5: Maximum word limit 150 words. (2 marks)
Following treatment, Mr McDonald’s bleeding varices settled, and he was discharged home on the following medications: Lactulose orally 20 mL BD, Spironolactone 50mg mane. Explain the reason for each of these in relation to his underlying disease process.
Scenario 2 (Total 11 marks)
You are a new graduate registered nurse working in the paediatric ward of your local hospital.
Sam Nicolaides is a nine-year-old boy who until recently has been in good health. Sam lives with his mother and father and two siblings. Following a respiratory virus a few weeks ago he has been slow to recover, lacking in his usual energy. He has been hungry and thirsty all the time, and has recently begun wetting the bed, which he has not done for many years.
Sam presented to the Accident and Emergency department two day ago with nausea, abdominal pain and feeling generally unwell. His observations taken on admission were:
Blood pressure 80/50mmHG, pulse 140, respiratory rate 28 deep and sighing with an unusual sweet smell to the breath, oxygen saturation 100%, temperature 37.2 degrees Celsius. Urinalysis SG1025, pH 5, sugar++++ ketones+++ no other abnormalities. BGL 28mmol/L.
A medical diagnosis of Diabetes type 1 with keto-acidosis was made.
Question 6. Maximum word limit 120 words (approximately 30 words per section) (2 marks)
Briefly explain the pathophysiology causing the following symptoms Sam was experiencing on admission:
Question 7. Maximum word limit 50 words. (2 marks)
List four (4) ongoing nursing assessments, other than vital signs, that will be required to monitor Sam’s fluid status and ensure safe fluid replacement therapy over the next 48 hours.
Question 8. Maximum word limit 150 words. (3 marks)
Explain the concept of family centred care and why this is important to the physical and psychological care for Sam.
Question 9. Maximum word limit 150. (2 marks)
For the ongoing management of type 1 diabetes, current best practice recommends an intensive insulin therapy regime called multiple dose insulin (MDI) or basal/bolus regime. Explain:
Question 10. Maximum word limit 150 words (2 marks)
Explain what the HbA1c test is and why it is important in the management of patients with diabetes.
Scenario 3 (Total 11 marks)
You are a Practice Nurse in a small rural medical centre.
Mr Stuart Murray is a 48-year-old Indigenous man living with his family in a small rural town in NSW. Mr Murray has a medical history of type 2 diabetes, obesity and hypertension. Mr Murray drinks at least five schooners of beer and smokes up to 20 cigarettes daily. He is currently suffering from tiredness, breathlessness on exertion, swollen ankles, nausea, itchy skin and aching bones and joints. He passes about 400 mL of urine in 24 hours.
Mr Murray presents to his local medical centre saying he was not feeling well. Mr Murray’s regular medications are metformin and ramipril. You assess Mr Murray and reviews the pathology tests the doctor ordered.
Question 11. Maximum word limit 20 words. (1 mark)
You are concerned that Mr Murray is at risk of, or is, developing Chronic Kidney Disease (CKD). Based on the scenario above, list the risk factors for CKD that are applicable to Mr Murray.
Question 12. Maximum word limit 20 words. (1 mark)
List the three recommend tests that form the kidney health check, to determine if Mr Murray is developing CKD.
Question 13. Maximum word limit 10 words. (1 mark)
Based on the physical assessment and the pathology test results, what stage of CKD is Mr Murray currently experiencing?
Question 14. Maximum word limit 300 words. (5 Marks)
Mr Murray’s doctor prescribes the following dietary modifications and additional medications.
As the Practice Nurse in the medical centre, you explain to Mr Murray how each of these treatments are related to his failing kidney function, how they will improve his health, and how he should take them. Outline your explanation for each.
Question 15. Maximum word limit 150 words. (3 marks)
The doctor tells Mr Murray that he will need to go to the nearest large town for a specialist consultation and treatment. Mr Murray is not sure that he wants to go.
Scenario 4 (Total 13 marks)
A new graduate nurse is working in a surgical ward of the local hospital. She has been allocated to care for Mrs Beverly Smith, a 70-year-old woman admitted for a hemicolectomy for stage 2 bowel cancer. Mrs Smith has a history of hypertension and stage 2 Chronic Kidney Disease (CKD). Mrs Smith had her surgery yesterday and is reported to have been stable overnight. She has a midline incision closed with staples, one Belovac of with minimal haemo-serous drainage, IV 4% Dextrose in 1/5 Normal Saline running at 85mL/hr and a PCA of Morphine sulphate 100mg in 100mL Normal Saline set to deliver 1mg with each press. She has an indwelling urinary catheter draining an average of 60mL/hr.
When the nurse assesses Mrs Smith at the beginning of the shift, she appears distressed and complains of pain rated 7 out of 10 in her abdominal area. Her observations are blood pressure 140/85 mmHg, pulse 90 bpm, respiratory rate 12, oxygen saturation 92% and temperature 36.2 degree Celsius. She is unwilling to sit up in bed and has difficulty taking a deep breath.
The nurse explains to Mrs Smith the importance of pressing the PCA button regularly. She then checks her medication chart for any orders for “breakthrough” medication. Mrs Smith has an order for oxycodone (Endone) 10mg oral PRN, so the RN asks the endorsed EN to accompany her to the locked medication cupboard, check out the dose of Endone, and administer it to Mrs Smith, checking all the “5 rights” of medication administration.
The RN continues to give care to her other patients. When she returns to the room, she notes that Mrs Smith is sleeping peacefully. Because she had a poor night, she decides not to wake her for observations and charts “sleeping” on her PCA chart. The nurse then goes to morning tea.
When she returns from morning tea, she notes that Mrs Smith is slumped down in the bed and looks very pale. She does a set of observations and notes the following:
Patient is semi-conscious, rousing to voice, unable to give a pain score, PCA history delivered dose 15 times in the last 2 hours, blood pressure 90/60mmHg, pulse 70 bpm, respiratory rate 4 breaths per minute and shallow, oxygen saturation 84%.
Question 16. Maximum word limit 50 words. (1 mark) (Reference not required for this question)
Express the immediate priority patient problem indicated by this situation as a Nursing Diagnosis with a ‘Related to’ and ‘Evidenced by’ statement.
Question 17. Maximum word limit 200 words. (4 marks)
List four immediate priority nursing actions that are required in this situation to address the identified problem and a rationale for each.
Questions 18.Maximumword limit 200 words. (3 marks)
Discuss what you believe were the main patient factors and nursing or system errors, that led to this occurrence.
Question 19. Maximum word limit 150 words. (2 marks)
Following treatment by the medical and nursing team, Mrs Smith is significantly improved by the time her daughter visits later.
Describe the actions required following this incident as part of NSW Health and hospital policy to address issues of patient safety and standards of care.
Question 20. Maximum word limit 200 words. (3 marks)
What are the legal requirements for a Tort of negligence? Do you believe that the new graduate RN was negligent in this situation? Justify your answer.
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