SWIFT RIVER MED SURG PT
SCENARIOS: EXAM, 2025/2026 WITH
CORRECT/ACCURATE ANSWERS
Sarah Getts, 77 yr-old, Dx- Chronic Renal Failure, admitted with
hyperkalemia (5.9, Eq/L)/hyponatremia (128mEq/L). No known
allergies (NKA). Vital signs -Temp 98.8, BP 102/76, P 102-
irregular, RR 22, SaO2 90%, cardiovascular on telemetry with
Sinus irregular rhythm. Disoriented to time and place, speech
slurred. Pupils PERRLA, eyes clear. 20 ga. Hep-Lock in right
forearm, skin warm and dry, generalized weakness with recent
weight loss. 50% intake. High fall risk. Renal diet. Family in room
with patient very concerned. Dr. Brown - CORRECT ANSWERS-
Educational Needs Increased acuity
Fall Risk Increased acuity
Health Change Increased acuity
Pain Level Normal acuity
Psychological Needs Increased acuity
Sensorium Increased acuity
Sarah Getts - CORRECT ANSWERS- Physiological
Acute Pain False
Deficient Fluid Volume False
,Electrolyte Imbalance True
Imbalanced Fluid Volume, Risk for True
Impaired Skin Integrity, Risk for False
Ineffective Renal Perfusion, Risk for True
Safety
Acute Confusion True
Disturbed Sensory Perception False
Fall, Risk for True
Sleep Deprivation False
Love and belonging
Anxiety False
Failure to Thrive True
Sarah Getts
Scenario 1
Ms. Getts is requesting water to drink. Her pitcher has already
been filled three times this shift.
Scenario 2
,Three hours later, Ms. Getts is unsteady when standing by her
bedside.
Scenario 3
You observe Ms. Getts being assisted by another nurse who is
being blatantly rude and disrespectful to her.
Scenario 4
Ms. Getts is now complaining of sudden sharp, substernal chest
pain, very short of breath and is profusely diaphoretic.
Scenario 5
Ms. Getts is being transferred as an emergency to Critical Care.
Your responsibilities are: - CORRECT ANSWERS- Scenario 1
Wash and glove hands
Full assessment
Monitor and evaluate fluid intake
Educate patient
Document results
Scenario 2
Wash and glove hands
Full assessment
Apply fall risk bracelet
, Document results
Scenario 3
Offer assistance
Remain with patient
Therapeutic Communication
Notify lead nurse
Document results
Scenario 4
Visual assess
Call rapid response
Apply oxygen
Establish second IV
Remain with patient
Scenario 5
Give verbal report
Escort patient
Notify family
Document results
SCENARIOS: EXAM, 2025/2026 WITH
CORRECT/ACCURATE ANSWERS
Sarah Getts, 77 yr-old, Dx- Chronic Renal Failure, admitted with
hyperkalemia (5.9, Eq/L)/hyponatremia (128mEq/L). No known
allergies (NKA). Vital signs -Temp 98.8, BP 102/76, P 102-
irregular, RR 22, SaO2 90%, cardiovascular on telemetry with
Sinus irregular rhythm. Disoriented to time and place, speech
slurred. Pupils PERRLA, eyes clear. 20 ga. Hep-Lock in right
forearm, skin warm and dry, generalized weakness with recent
weight loss. 50% intake. High fall risk. Renal diet. Family in room
with patient very concerned. Dr. Brown - CORRECT ANSWERS-
Educational Needs Increased acuity
Fall Risk Increased acuity
Health Change Increased acuity
Pain Level Normal acuity
Psychological Needs Increased acuity
Sensorium Increased acuity
Sarah Getts - CORRECT ANSWERS- Physiological
Acute Pain False
Deficient Fluid Volume False
,Electrolyte Imbalance True
Imbalanced Fluid Volume, Risk for True
Impaired Skin Integrity, Risk for False
Ineffective Renal Perfusion, Risk for True
Safety
Acute Confusion True
Disturbed Sensory Perception False
Fall, Risk for True
Sleep Deprivation False
Love and belonging
Anxiety False
Failure to Thrive True
Sarah Getts
Scenario 1
Ms. Getts is requesting water to drink. Her pitcher has already
been filled three times this shift.
Scenario 2
,Three hours later, Ms. Getts is unsteady when standing by her
bedside.
Scenario 3
You observe Ms. Getts being assisted by another nurse who is
being blatantly rude and disrespectful to her.
Scenario 4
Ms. Getts is now complaining of sudden sharp, substernal chest
pain, very short of breath and is profusely diaphoretic.
Scenario 5
Ms. Getts is being transferred as an emergency to Critical Care.
Your responsibilities are: - CORRECT ANSWERS- Scenario 1
Wash and glove hands
Full assessment
Monitor and evaluate fluid intake
Educate patient
Document results
Scenario 2
Wash and glove hands
Full assessment
Apply fall risk bracelet
, Document results
Scenario 3
Offer assistance
Remain with patient
Therapeutic Communication
Notify lead nurse
Document results
Scenario 4
Visual assess
Call rapid response
Apply oxygen
Establish second IV
Remain with patient
Scenario 5
Give verbal report
Escort patient
Notify family
Document results
