Patient Scenario
M.N., age 65, is admitted to your surgical floor after an open cholecystectomy for acute cholecystitis. She has a nasogastric tube to continuous low wall suction, one peripheral IV line, and a large abdominal dressing. Her current orders include:
- Clear liquid diet; progress low-fat diet as tolerated
- D5 ½NS with 40 mEq KCl at 125 mL/hr
- Turn, cough, and deep breathe q2h
- Incentive spirometer q2h while awake
- Oxygen per protocol to maintain SpO2 at 95%
- Dangle in a.m.
- Morphine sulfate 10 mg IM q4h prn for pain
- Piperacillin/tazobactam (Zosyn) 3.375 g IV q6h
- CXR in a.m.
1. Are these orders appropriate for M.N.? State your rationale.
Progress Note #1
At 1530, the UAP reports: BP 148/82, HR 118, RR 24, Temp 101°F (38.3°C), SpO2 92%.
2. Based solely on these vital signs, what could be happening, and why?
[Select all that apply]
3. You go to assess M.N. What do you need to include in your assessment at this time?
[Classify each action: “Relevant Now,” “Possibly Relevant,” or “Not Relevant.”]
| Assessment Action | Relevant Now | Possibly Relevant | Not Relevant |
|---|---|---|---|
| Auscultation of lungs | |||
| Assessment of incision site | |||
| Measuring urinary output | |||
| Quality of cough or sputum | |||
| GI function / bowel sounds |
Progress Note #2
Assessment reveals decreased breath sounds and crackles in the right base posteriorly. Right middle and lower lobes percuss slightly dull. M.N. splints her right side with deep breaths. No productive cough, chest pain, or anxiety. Skin is pale, warm, and dry.
4. What complication do you suspect? State your rationale.
Drag & drop the correct items:
5. Why is M.N. at risk for this complication?
[Drop-down fill in the blank]
Post-operative patients are at increased risk for because of . Another factor is , which can .
6. What is your nursing priority now?
[Multiple Choice]
7. Describe 6 interventions you will perform over the next few hours based on this priority.
[Select all that apply]
8. Which actions could you delegate to the UAP?
[Select all that apply]
Type your final picks (e.g., C, D, F):
9. Identify 3 SMART goals. What does “SMART” stand for?
Progress Note #3
At 1830, the UAP reports: BP 136/72, HR 104, RR 24, Temp 100.6°F (38.1°C), SpO2 93%.
10. Has M.N.’s status improved or not? Defend your response.
[Match Yes/No]
| Statement | Choice |
|---|---|
| Temperature decreased from 101°F to 100.6°F, HR from 118 to 104 | |
| SpO2 still below 95%, RR remains elevated at 24 |
11. Using SBAR, what would you report to the surgeon?
| Item | S (Situation) | B (Background) | A (Assessment) | R (Recommendation) |
|---|---|---|---|---|
| Patient’s vitals: T 100.6°F, RR 24, HR 104, SpO2 93% | ||||
| M.N. is post-op day 1 from open cholecystectomy | ||||
| I suspect atelectasis due to decreased breath sounds/dullness on percussion | ||||
| Request a stat CXR or consider adjusting antibiotic coverage |
12. The radiology report confirms atelectasis. Should your plan of care change?
13. If M.N. had pneumonia, what changes might the surgeon have made?
14. M.N.’s sister says, “She came in with a bad gallbladder. Now she has lung issues?” How would you respond?
[Multiple Choice]