Criteria 2: Current Clinical Knowledge & Clinical Problem Solving

Question 1

As a Registered Nurse, you will be working in a teamwork environment.
Within a month of commencing work, you will be responsible for a number
of patients.
Halfway through your shift, you realised you do not have time to complete
your work? What would you do?

Answer 1

As a RN I understand that time management and team work is important. This allows for safe patient care, that is holistic. Each patient deserves care that is tailored to there needs. Duty of care.

Apply time management strategies, time management list
 Priority setting/ most important to lest, work through list
 Appropriate delegation
 Advise NUM, preceptor, team members, educator
 Ask for help
 Hand over uncomplicated tasks to the next shift
 Documentation
 Reflect on what you can improve next time

Question 2

PRORITATSATION QUESTION

Answer 2

• Each patient I have a duty of care. No patient is more imporatant that another. Deserve PCC (Mccormack n McCance). May have competing priorities..

 Prioritisation & delegation skills
 Assess patients & prioritise care according to assessment
 Asks other staff for help
 Identifies teamwork is important
 Identify risks/ possible difficulties
 Follow up with appropriate staff/ Dr etc
 Communications concerns to others
 Documents all care
 Reflect on what you can improve next time

Question 3

A patient you are caring for has fallen in the bathroom. Their IV cannula has
dislodged and is bleeding from the site.
How would you manage this situation?

Answer 3

 Call for assistance
 Assess the patient
 Standard precautions - PPE: blood spill
 Moving safely policy adhered to: no lifting
 OH&S principles: water on the floor?
 OH&S principles
 Privacy/dignity issues
 Appropriate medical review
 Incident notification
 Documentation

Question 4

When answering a call to the bathroom, a patient directs you to a person
lying on the floor who is bleeding from the head.
What would you do in this situation?

Answer 4

Safety for self and others
 Call for help
 DR ABC
 Assess patient
 Observations including neurological assessment
 Infection Control principles including PPE
 Incident notification
 Maintain privacy and dignity
 Documentation
 Reassure other patients
 OH&S
 Manual Handling
 Informs relevant staff ie DR

EXAMPLE - ICU

Question 5

You walk into one of your allocated patient rooms and find a patient
unresponsive.
What would you do in this situation?

Answer 5

 Assess patient
 DR ABC
A - clear airway using head tilt/chin lift or jaw thrust. Nasopharyngeal airway or oropharyngeal airway. 
B - the effort of breathing, RR and skin colour. Oxygen; bag value mask 10-15 l (1-12 BMP)
 CPR if required (100-120 BMP)
 Maintain pts privacy and dignity
 Observations & Oxygen
 Documentation
 Reassure other patients
 Informs relevant staff ie DR

Question 6

You are looking after a patient who is becoming increasingly paranoid that
staff on the ward are trying to harm them.
How would you deal with this patient

Answer 6

Who becomes paranoid ? MH, Dementia, Delirium.

 Assess patient, review history and progress notes
 Policies/procedures
 Consult with senior staff
 Safety self, patient and others
 Notify medical officer
 Communication, diversional therapy etc
 Document
 Don’t ignore continually engage the pt and seek outcome
 If available contact CNC or CNS in MH to help develop strategies of
management

EXAMPLE : SAGU

Question 7

While checking a dose of antibiotics for your patient, you calculate that the
dose is twice the recommended amount. When you check the patients
chart, you notice the same medication dose was given 6 hours ago.
What would you do in this situation?

Answer 7

 Assess the pt, vital signs
 Recheck orders on medication chart
 Double check calculation and ask second nurse to check again
 Consult with nurse who looked after pt on previous shift / DR looking after the
patient
 Let staff know that the order is double the normal dose
 If incorrect: contact Dr to re-chart drug
 Inform NUM/ team leader
 Incident notification
 Do NOT give the drug until order confirmed
 Document in patient notes

Question 8

At the beginning of your shift, you are looking after a patient who was
admitted with an overdose. When you go to introduce yourself she is not in
her bed or anywhere to be seen.
What would you do?

Answer 8

 Check the entire ward area.
 Consult with nurse who looked after the patient on previous shift to see if they
know where the patient is and ask RN when last saw the patient
 Check whether patient has gone for a procedure/test, or gone for a walk
 Inform Team leader, NUM & MO
 Call security –description of patient
 Call next of kin
 Incident notification and other Documentation
 Team Leader may need to notify police if patient is a risk to self or others or if not
at home and does not return
 Assess how it happened to decrease the risk of it happening again

Question 9

You are caring for a patient with a history of self harm. They are on close
observations and have asked you to take them to the shop.
What would you do?

Answer 9

 Discuss with patient
 Policies/procedures
 Consult with other staff
 Safety of self, patient, others
 Know own limits
 Set boundaries
 Inform other staff of plan and actions

Question 10

Seizure

Answer 10

 Assess patient + call for help
 DR ABC
A - clear airway using head tilt/chin lift or jaw thrust. Nasopharyngeal airway or oropharyngeal airway.
B - the effort of breathing, RR and skin colour. Oxygen
C (circulation) - HR (brady, tachy), pulse, BP.
D - AVPU, Pupil size ; change my indicate raised ICP. ECG
E - wounds, infection? can be cause
F - fluid overload, enough fluid
G - bgl e.g. hypoglycemia
Anti-epileptic medication
VItals

 Maintain pts privacy and dignity
 Documentation
 Reassure other patients
 Informs relevant staff ie DR

• blood FBC, ELFT
• Drug results
• review HX
• CT + MRI
• Head to toe

Question 11

Chest pain

Answer 11

Assess pt. 
Call for help 
PQRST 
ECG
Asprin 300 mg
Bloods - troponin
Analgesia - standing orders 
GTN 
DRABC if unresponsive

 Maintain pts privacy and dignity
 Documentation
 Reassure other patients
 Informs relevant staff ie DR
frequent observaitons

• thrombalise if appropriate

Question 12

Respiratory Arrest

Answer 12

• Assess patient; vital signs; Sp02 aim above 95%
• Call for help
• Assess reason for RA: airway and breathing,? is it blocked clear airway using head tilt/chin lift or jaw thrust. Nasopharyngeal airway or oropharyngeal airway. Intubation? Suction?
• apply supplementary oxygen
• sit upright
  Unresponsive = CPR
  Maintain pts privacy and dignity
   Documentation
   Reassure other patients
   Informs relevant staff ie DR
• chest x-ray
• Bloods
• fluid management