SWIFT RIVER MED-SURG MAIN EXAM 2025/2026
QUESTIONS WITH SOLUTIONS GRADED A+
✔✔Marcella Como - ✔✔Physiology-
Acute Pain: True
Impaired mobility: False
Impaired urinary elimination: False
Readiness for enhanced immunization status: True
Esteem-
Decisional conflict: False
Ineffective coping: True
Noncompliance: False
Rape-trauma syndrome: True
Safety-
Chronic confusion: False
Fall, Risk for: False
Fear: True
Grieving: True
Infection, risk for: True
Sleep deprivation: False
Self-actualization-
Disturbed energy field: True
Spiritual distress: False
Love and Belonging-
Anxiety: True
Body image, Disturbed: False
Chronic sorrow: False
Compromised family coping: True
Powerlessness: False
Social isolation: True
✔✔Marcella Como
Scenario 1
Ms. Como is first day after sexual assault. Upon entering the room, she is quiet and
shows little emotion.
,Scenario 2
Later in morning care, Ms. Como requests o take a shower stating she feels 'dirty'.
Scenario 3
In the afternoon, Ms. Como is stating that she does not want to see her husband or any
visitors.
Scenario 4
Marcella Como is now more talkative and shares with you that she is going to cooperate
and wants to press charges against the assailant.
Scenario 5
Marcella is very worried about STD's and posssible pregnancy - ✔✔Scenario 1
Use therapeutic communication/active listening
Full assessment
Provide emotional support
Documentation
Scenario 2
Use therapeutic communication/ active listening
Educate pt
Provide supplies and needed instructions
Offer to assist
Scenario 3
Use therapeutic communication/active listening
Ask open-ended questions
Seek clarification
Summarize discussion
Scenario 4
Restate or paraphrase pt statements
Acknowledge pt's decision
Review plan of action
Notify social services
Document process
Scenario 5
Review labs
Educate pt-STD's and pregnancy
Provide emotional support
Discuss support groups
✔✔Preston Wright - ✔✔Educational Needs: Increased acuity
Fall Risk: Increased acuity
Health Change: Increased acuity
,Neurological: Normal acuity
Pain Level: Increased acuity
Psychological Needs: Normal acuity
✔✔Preston Wright - ✔✔Physiological -
Acute Pain: True
Altered Body Image: True
Constipation: False
Impaired Communication: False
Impaired Physical Mobility: True
Impaired Tissue Integrity: True
Ineffective Airway Clearance: False
Ineffective Breathing Pattern: False
Risk for Imbalanced Nutrition: True
Safety-
Isolation Precaution: False
Risk for Infection: True
Risk for Injury related to Falls: True
✔✔Preston Wright
Scenario 1
Mr. Wright reports pain 6/10, and is requesting medication prior to dressing change
Scenario 2
Mr. Wright insists that he watches TV from the Hight Fowler's position. The nurse
repositioned the pt to the left side to decrease pressure on the sacrum and rt heel.
Sacrum pressure injury demonstrates underlying bone exposure wound measures 4cm
x 6cm x 3cm depth w/ tunneling noted on the rt side. The rt heel demonstrates a blister
2cm x 1cm w/ clear fluid noted.
Scenario 3
The HCP is requesting an update on sacral wound healing.
Scenario 4
It is now times for Mr. Wright's sacral dressing change as the dressing seal is
compromised and drainage is visible on the outer layer. see the plan of care: 1.) Sterile
NS wet-to-dry dressing changes daily 2.) Apply triple abx ointment to edges of wound
each dressing change 3.) Notify MD of worsening changes to wound based on
measurements and appearance 4. - ✔✔Scenario 1
Assess current pain level
Assess documented pain level and intervention by previous nurses
Review medication orders for pain
, Prepare and administer appropriate pain medication
Reassess pain level
Scenario 2
Assess Mr. Wright's willingness to learn.
Eliminate as many distractions as possible.
Explain rationales for pressure relief to injured areas.
Assess understanding through teach back.
Document responses.
Scenario 3
Remove old dressing w/ clean gloves daily
Assess the injury for presence of necrotic tissue and amount of exudate.
Assess and document the condition of the skin surrounding the pressure injury in terms
of color, temperature, texture and moisture.
Measure wound size at greatest length, width and depth using a disposable paper tape
measure.
Re-apply new sterile dressing.
Scenario 4
Don clean gloves and removed the old dressing.
Remove clean gloves, wash hands, put on sterile gloves
Clean wound the sterile saline, apply triple abx ointment per HCP order.
Place sterile moistened sterile gauze in wound, place ABD pad over wound.
Secure dressing place with tape
Scenario 5
Explain s/sx of wound infection.
Encourage Mr. Wright to include high protein snacks in his diet
Assess understanding through teach back
Alert Mr. Wright's case manager of concerns of home environment.
call report to home care RN
✔✔John Duncan - ✔✔Educational Needs: Increased acuity
Fall Risk: Increased acuity
Health Change: Increased acuity
Pain Level: Increased acuity
Psychological Needs: Normal acuity
Sensorium: Normal acuity
✔✔John Duncan - ✔✔Physiological -
Deficient Fluid Volume: True
Electrolyte Imbalance, Risk for: True
Excess Fluid Volume, Risk for: False
Fatigue: True
QUESTIONS WITH SOLUTIONS GRADED A+
✔✔Marcella Como - ✔✔Physiology-
Acute Pain: True
Impaired mobility: False
Impaired urinary elimination: False
Readiness for enhanced immunization status: True
Esteem-
Decisional conflict: False
Ineffective coping: True
Noncompliance: False
Rape-trauma syndrome: True
Safety-
Chronic confusion: False
Fall, Risk for: False
Fear: True
Grieving: True
Infection, risk for: True
Sleep deprivation: False
Self-actualization-
Disturbed energy field: True
Spiritual distress: False
Love and Belonging-
Anxiety: True
Body image, Disturbed: False
Chronic sorrow: False
Compromised family coping: True
Powerlessness: False
Social isolation: True
✔✔Marcella Como
Scenario 1
Ms. Como is first day after sexual assault. Upon entering the room, she is quiet and
shows little emotion.
,Scenario 2
Later in morning care, Ms. Como requests o take a shower stating she feels 'dirty'.
Scenario 3
In the afternoon, Ms. Como is stating that she does not want to see her husband or any
visitors.
Scenario 4
Marcella Como is now more talkative and shares with you that she is going to cooperate
and wants to press charges against the assailant.
Scenario 5
Marcella is very worried about STD's and posssible pregnancy - ✔✔Scenario 1
Use therapeutic communication/active listening
Full assessment
Provide emotional support
Documentation
Scenario 2
Use therapeutic communication/ active listening
Educate pt
Provide supplies and needed instructions
Offer to assist
Scenario 3
Use therapeutic communication/active listening
Ask open-ended questions
Seek clarification
Summarize discussion
Scenario 4
Restate or paraphrase pt statements
Acknowledge pt's decision
Review plan of action
Notify social services
Document process
Scenario 5
Review labs
Educate pt-STD's and pregnancy
Provide emotional support
Discuss support groups
✔✔Preston Wright - ✔✔Educational Needs: Increased acuity
Fall Risk: Increased acuity
Health Change: Increased acuity
,Neurological: Normal acuity
Pain Level: Increased acuity
Psychological Needs: Normal acuity
✔✔Preston Wright - ✔✔Physiological -
Acute Pain: True
Altered Body Image: True
Constipation: False
Impaired Communication: False
Impaired Physical Mobility: True
Impaired Tissue Integrity: True
Ineffective Airway Clearance: False
Ineffective Breathing Pattern: False
Risk for Imbalanced Nutrition: True
Safety-
Isolation Precaution: False
Risk for Infection: True
Risk for Injury related to Falls: True
✔✔Preston Wright
Scenario 1
Mr. Wright reports pain 6/10, and is requesting medication prior to dressing change
Scenario 2
Mr. Wright insists that he watches TV from the Hight Fowler's position. The nurse
repositioned the pt to the left side to decrease pressure on the sacrum and rt heel.
Sacrum pressure injury demonstrates underlying bone exposure wound measures 4cm
x 6cm x 3cm depth w/ tunneling noted on the rt side. The rt heel demonstrates a blister
2cm x 1cm w/ clear fluid noted.
Scenario 3
The HCP is requesting an update on sacral wound healing.
Scenario 4
It is now times for Mr. Wright's sacral dressing change as the dressing seal is
compromised and drainage is visible on the outer layer. see the plan of care: 1.) Sterile
NS wet-to-dry dressing changes daily 2.) Apply triple abx ointment to edges of wound
each dressing change 3.) Notify MD of worsening changes to wound based on
measurements and appearance 4. - ✔✔Scenario 1
Assess current pain level
Assess documented pain level and intervention by previous nurses
Review medication orders for pain
, Prepare and administer appropriate pain medication
Reassess pain level
Scenario 2
Assess Mr. Wright's willingness to learn.
Eliminate as many distractions as possible.
Explain rationales for pressure relief to injured areas.
Assess understanding through teach back.
Document responses.
Scenario 3
Remove old dressing w/ clean gloves daily
Assess the injury for presence of necrotic tissue and amount of exudate.
Assess and document the condition of the skin surrounding the pressure injury in terms
of color, temperature, texture and moisture.
Measure wound size at greatest length, width and depth using a disposable paper tape
measure.
Re-apply new sterile dressing.
Scenario 4
Don clean gloves and removed the old dressing.
Remove clean gloves, wash hands, put on sterile gloves
Clean wound the sterile saline, apply triple abx ointment per HCP order.
Place sterile moistened sterile gauze in wound, place ABD pad over wound.
Secure dressing place with tape
Scenario 5
Explain s/sx of wound infection.
Encourage Mr. Wright to include high protein snacks in his diet
Assess understanding through teach back
Alert Mr. Wright's case manager of concerns of home environment.
call report to home care RN
✔✔John Duncan - ✔✔Educational Needs: Increased acuity
Fall Risk: Increased acuity
Health Change: Increased acuity
Pain Level: Increased acuity
Psychological Needs: Normal acuity
Sensorium: Normal acuity
✔✔John Duncan - ✔✔Physiological -
Deficient Fluid Volume: True
Electrolyte Imbalance, Risk for: True
Excess Fluid Volume, Risk for: False
Fatigue: True
