Question 1
John Wiggins Scenario 4
Mr. Wiggins's level of consciousness has deteriorated throughout the day. During his initial assessment, his Glasgow Coma
Scale was 15. The healthcare provider asks what his current Glasgow Coma Scale is, you report his Glasgow Coma Scale is
now 11. What part(s) of the GCS should be included?
Correct Answer
The patient opens his eyes to speech
The patient is confused and/or uses inappropriate words
The patient has difficulty obeying commands but localizes pain
Question 2
John Wiggins Scenario 2
Upon examination, you found that the patient's pupillary were not equal bilaterally.
Correct Answer
Document size and reaction time of each pupil
Ask the patient if a healthcare provider has noted unequal pupils before
Notify the healthcare provider of finding immediately
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,Question 3
Donald Lyles Scenario 1
You are administering Insulin for Mr. Lyles. What do you do with the needle immediately after injecting the patient?
Correct Answer
Dispose syringe in sharps container
Engage Safety
Question 4
Kenny Barrett Room 302
Kenny Barrett, 64 years old, was admitted for observation of initial administering of BP his treatment with blood pressure of
220/124 after visiting his doctor for a routine physical. ECG was unremarkable. No past history of HTN. Past medical history
includes hyperlipidemia, current elevated triglycerides, and a history of 1 pack a day smoker for the past 20 years. Vital
signs are Temp 98.9F, BP 178/90, P 88, RR 18 SaO2 95% on Room air. IV with NS @ 125 mL/ hr. Patient has been
complaining of a headache and dizziness. He is a patient of Dr. Adams.
Correct Answer
Addiction
Perfusion
Question 5
Kenny Barrett Scenario 5
In continuing with the SBAR, what should be included in the "R"?
Correct Answer
Request for change in IV rate from 125mL/hr. to 50mL/hr.
Suggest/ask for an anti-hypertensive medication
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,Question 6
Linda Pittmon Scenario 4
Surgery called to the unit to inform the nurse that Ms. Pittmon has been scheduled at 1300 for a Below the Knee
amputation. The patient has become confused and combative and has pulled out her IV. She is a tough IV stick, and it took
several attempts previously.The Preop nurse tells the floor nurse to have the patient sign the consent, restart the IV, and
anesthesia will see the patient in the preop hold. What actions does the nurse take?
Correct Answer
Wait until anesthesia evaluates the patient and have them assist in restarting the IV.
Notify anesthesia to come to the floor to evaluate the patient.
Have the next of kin sign the operative consent if available.
Question 7
Kathy Gestalt Scenario 1
You enter the patient's room in response to a call light; Kathy is complaining of pain.
Correct Answer
Ask the patient to rate her pain on a scale of 1-10
Check to see the last time the patient received pain medication
Ask the patient what has made the pain better?
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, Question 8
Tim Jones Scenario 2
While attempting to inspect the patient's wounds, he is fearful of your physical advances. How will you develop a sense of
trust with the patient?
Correct Answer
Reduce external stimuli
Sit at the patient's eye level and ensure they can see your lip movement and facial expression
Speak slowly in a normal tone of voice
Sit quietly with the patient allowing them enough time to respond
Question 9
John Wiggins Scenario 5
You have reported the decreased Glasgow Coma Scale to the Provider. They are on their way in. Select appropriate
interventions in the meantime.
Correct Answer
Ensure side rails are up and the bed is in the lowest position
Ensure patient is NPO untiled advised otherwise
Provide one-to-one care until the Provider arrives
Elevate the head of the bed 30 degrees
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