Foundations of Nursing: Stepped Case Study

2. Pain Management: Assessing & Planning

Scenario Point: Mr. Green reports chest discomfort and generalized “ache,” rating 6/10. He's on IV PCA morphine + PRN acetaminophen.

Question: What nonpharmacologic interventions could you add to help alleviate his pain? (Select all that apply.)

• Guided imagery or relaxation techniques
• Repositioning in bed for comfort
• Application of cold compress to the chest
• Splinting his chest with a pillow when coughing

Check Answer

3. Health Assessment: Focused vs. Head-to-Toe

Question: Given Mr. Green’s presentation, which focused assessments take priority at the start of your shift?

• Neurological check (orientation, pupils, GCS)
• Respiratory assessment (lung sounds, sputum, SpO₂)
• Full integumentary check for pressure injuries
• Bowel sounds and last BM

Check Answer

4. Asepsis & Infection Control

Scenario Point: Mr. Green’s sputum culture indicates pneumonia. IV antibiotics started. Foley in place.

Question: Which infection-control measures are most crucial to prevent complications? (Select all that apply.)

• Strict hand hygiene before and after contact
• Using appropriate PPE (gloves, gown if contact with bodily fluids)
• Ensuring Foley catheter care every shift
• Double-gloving for all vital sign checks

Check Answer

5. Neuro & Sensory Assessment

Scenario Point: Mr. Green is occasionally forgetful with mild confusion, possibly due to hypoxia, fever, or infection.

Question: Which interventions best ensure patient safety and support his cognition? (Select all that apply.)

• Keep the room well lit and the bed in low position
• Apply bilateral wrist restraints to prevent falls
• Use a clock and calendar in the room to help reorient him
• Speak calmly, reorient to time and place when confusion arises

Check Answer

6. Musculoskeletal & Fall Precautions

Scenario Point: Mr. Green has knee osteoarthritis, general weakness, moderate fall risk (Morse Scale).

Question: Which interventions reduce Mr. Green’s fall risk? (Select all that apply.)

• Place personal items and call bell within reach
• Teach Mr. Green to use a walker or cane if needed
• Use side rails ×4 to keep him in bed
• Post a “fall risk” sign outside the door

Check Answer

7. Hematology & Lab Monitoring

Scenario Point: WBC 14,500 (infection), BUN/Creatinine elevated (possible dehydration, mild AKI).

Question: Based on labs and clinical presentation, which nursing interventions are appropriate? (Select all that apply.)

• Increase IV fluid rate if ordered or clarify with provider
• Assess intake & output closely, including Foley output
• Restrict fluids to 1,000 mL/day
• Check vital signs for orthostatic changes

Check Answer

8. Integumentary & Pressure Injury Prevention

Scenario Point: Coccyx area red but blanches with pressure (Stage I possible).

Question: What actions help prevent progression to a pressure ulcer? (Select all that apply.)

• Reposition Mr. Green at least every 2 hours
• Apply a moisture-barrier cream if incontinent or diaphoretic
• Place him on a high-protein diet (as tolerated)
• Rub vigorously over the reddened area to promote circulation

Check Answer

9. Gastrointestinal & Nutritional Support

Scenario Point: Poor appetite, no BM ×2 days.

Question: Which nursing diagnoses/interventions are most relevant? (Select all that apply.)

• “Constipation r/t decreased mobility and pain” → Increase fiber, fluids, stool softeners
• “Nausea” → Encourage clear liquid diet only
• “Imbalanced Nutrition: Less Than Body Requirements” → Provide small, frequent high-calorie meals
• “Bowel incontinence” → Insert a rectal tube

Check Answer

10. GU: Urinary Function & Catheter Care

Scenario Point: Foley output ~30 mL/hr, dark yellow urine, BPH history.

Question: What are your priority interventions regarding his urinary status? (Select all that apply.)

• Assess the catheter tubing for patency, no kinks or obstruction
• Obtain a urine culture if signs of infection (cloudy, foul odor, new confusion) appear
• Encourage increased oral fluids if not contraindicated
• Discontinue Foley if output is consistently under 30 mL/hr

Check Answer