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PART 1 - Danny  Khurana is a 20 year old male  currently in hospital  

Presenting complaint: 4hour post-operative patient. Underwent Laparotomy under
general anaesthesia to repair his small intestine and remove spleen. A temporary
Ileostomy has been performed. Danny is unable to look at his ileostomy site. He is also
feeling nauseas.   

History of presenting complaint: The patient was admitted via A&E following multiple
lacerations sustained in a knife attack  
Past medical history: Known to have reoccurring anxiety disorders. These are thought to
be attributed to Post-traumatic Stress Disorder following the death of his younger
brother. Weight = 85kg.  Type 1 diabetic. 
Social history: Has a stable girlfriend and has daughter of 2 years. He is a known gang
member. Unemployed. He is of South Asian British Heritage.  

Question 1
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On admission Danny was suffering from perfuse bleeding from his spleen, based on the
NCEPOD (2004) guidance on classifying the urgency of surgical procedures, how might
Danny’s need for theater be classified? (1 mark)
Select one:

a. Immediate 
b. Urgent
c. Expediated
d. Elective
Feedback
Your answer is correct.
The classification of surgery is as follows, 
IMMEDIATE – Immediate life, limb or organ-saving intervention – resuscitation simultaneous with
intervention. Normally within minutes of decision to operate. Life-saving or limb or organ saving
URGENT – Intervention for acute onset or clinical deterioration of potentially life-threatening
conditions, for those conditions that may threaten the survival of limb or organ, for fixation of
many fractures and for relief of pain or other distressing symptoms. Normally within hours of
decision to operate.

EXPEDITED – Patient requiring early treatment where the condition is not an immediate threat to
life, limb or organ survival. Normally within days of decision to operate.

ELECTIVE – Intervention planned or booked in advance of routine admission to hospital. Timing

to suit patient, hospital and staff.
 The answer to this question will be case-study specific. ie: in the case of Danny, he has
sustained life-threatening traumatic bleeding from his spleen requiring a Splenectomy.
Based on the urgency of this his classification for theater will be Immediate.
The correct answer is: Immediate
Question 2
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Danny is attending for unplanned surgery, what do the current standards state are the
normal fasting times be for Danny? (1 mark)
Select one:
a. Needs to be fasted after midnight if on morning list or after 6am if on the afternoon list (all meals
and fluids) 

b. Needs to be fasted for 6hours for light meals and 2hours for clear fluid 
c. Needs to be fasted from midnight (all meals and fluids) 
d. Surgery can be performed without fasting by undertaking rapid sequence induction (pressing on
cricoid cartilage during intubation).  
Feedback
Your answer is incorrect.
The European Society of Anaesthesiology (2011) guidelines consider patients should be
encouraged to drink clear fluids (including water, and tea or coffee without milk and any
carbohydrate loading drink) up to 2 h before surgery and Solid food should be prohibited for 6 h
before surgery. 
Our exception for this are for adults who are having immediate theater and under-going life-
saving interventions where a rapid sequence induction can be preformed to prevent the need for
fasting. In Danny's case, due to the life-saving operation required this is likely to be the guideline
he would follow. 
The correct answer is: Surgery can be performed without fasting by undertaking rapid sequence
induction (pressing on cricoid cartilage during intubation).  
Question 3
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Danny is a known type 1 diabetic patient on insulin, when he is prepared for
theater, based on the Association of Anaesthetists of Great Britain and Northern Ireland
(2015), what orders would the nurse expect? (1 mark)
Select one:
a. Commence patient on metformin prior to going to theatre
b. Commence patient on variable rate insulin infusion 
c. Give insulin as usually prescribed

d. Omit insulin on the morning of theatre 

Feedback
Your answer is incorrect.
Again whether a variable rate insulin infusion is given is dependent on the patient history. 
Variable-rate intravenous insulin infusions should be considered in:
 •patients who will miss more than one meal
•those with type-1 diabetes undergoing surgery who have not received background insulin;
•those with
•poorly controlled diabetes (defined as a HbA1c > 69 mmol/mol (>8.5%)
•most patients with diabetes requiring emergency surgery.

As Danny is both a type 1 diabetic patient and is requiring emergency surgery we would expect
him to be on a variable rate insulin infusion (sliding scale). 

The correct answer is: Commence patient on variable rate insulin infusion 
Question 4
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Danny has had a temporary ileostomy formed. Where is the most likely location of the
stoma aperture? (1 mark)
Select one:
a. Epigastric region
b. Umbilical region
c. Left lumbar region

d. Right iliac region 

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Your answer is correct.
The correct answer is: Right iliac region
Question 5
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Which finding requires immediate nursing action in a post-operative patient who has had
an ileostomy performed? (1 mark)
Select one:
a. The stoma is black

b. The stoma is red 

c. The stoma is tender
d. The stoma is warm
Feedback
Your answer is incorrect.
The correct answer is: The stoma is black
Question 6
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 As Danny has had an ileostomy stoma formed, once the stoma is functioning
appropriately, what are you expecting the stoma output to look like based on the
physiological pathways being bypassed? (1 mark)
Select one:
a. Type 2 or 3 on Bristol stool chart: Lumpy sausage like

b. Type 4 on Bristol stool chart: Like a smooth sausage or snake 

c. Type 5 or 6 on Bristol stool chart: Soft blobs
d. Type 7 on Bristol stool chart: Loose and watery
Feedback
Your answer is incorrect.
The correct answer is: Type 7 on Bristol stool chart: Loose and watery
Question 7
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Danny is complaining of post-operative nausea, what are the most appropriate nursing
interventions to manage post-operative nausea and vomiting (PONV)? (1 mark)
Select one:
a. Reduce all analgesia , give the patient a sick bowl and ensure they have the call bell
b. Reduce food and fluid intake, give analgesia and ensure patient comfortable
c. Reduce food and fluid intake, give anti-emetics and ensure you remain with patient

d. Reduce opioid use, give anti-emetics and ensure adequate hydration 

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Your answer is correct.
The correct answer is: Reduce opioid use, give anti-emetics and ensure adequate hydration
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Current medications: IVI Hartmans (1:6), Paracetamol 650mg QDS (IV), Ondansetron
4mg TDS (IV), Metronidazole 500mg TDS (IV), Cefuroxime 750mg TDS (IV). PCA of
1mg morphine/mL (1mL bolus, 5 minute lock out).
Drug history: Insulin (for diabetes). No over the counter medications or herbal remedies.
Has a criminal record for drug related offences and is a known smoker.

Question 8
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Danny has been prescribed morphine PCA, which of the following are typical side effects
of opioids administered by patient controlled analgesia? (1 mark)
Select one:
a. Hypoventilation, euphoria and ileus
b. Nausea, Diarrhoea and bradycardia
c. Sedition, pruritus and constipation 
Note: parts of other answers are also correct. However, all three need to be typical side-
effects for the answer to be correct.
d. Vomiting, dizziness and depression
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Your answer is correct.
The correct answer is: Sedition, pruritus and constipation
Question 9
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Danny is known to have previous recreational drug use, what impact may being opioid
tolerant have on Danny’s morphine PCA? (1 mark)
Select one:
a. He is not at risk of an opioid overdose

b. He may need a higher doses of morphine for it to be effective 

c. He may need a reducing dose of morphine to wean him off the addiction
d. He needs to be given methadone for his PCA to be effective
Feedback
Your answer is correct.
The correct answer is: He may need a higher doses of morphine for it to be effective
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On examination of Danny:
Ø  Cardiovascular System: HR = 98 (weak, regular) (baseline 80) BP = 110/90 (baseline
115/80)
Ø  Central Nervous System: Alert, Pupils equal and reacting to light
Ø  Gastrointestinal system and Renal System: Urinary catheter insitu 60mL (over 4 hrs).
Bowels = Ileostomy output in stoma bag of 0mL (over 4 hrs), Feeling nauseas. He is
complaining of a sore throat. 
Ø  Musculoskeletal and Integumentary System: Pressure Areas = intact. Non-blanching
redness on bridge of nose. Stoma site intact and well perfused.
Ø  Respiratory System: SpO2 = 97% (on 5L of oxygen via simple face mask) (baseline
98% on room air), RR = 14 (baseline 22), No use of accessory muscles, decreased
depth of breathing, No signs of central or peripheral cyanosis. Sputum = Clear/Watery.
No audible airway obstruction or wheeze.
Ø  Other - Endocrine System, Reproductive System, Immune System: Blood Sugar =
6.5mmol/L, Temp = 36.3   

Question 10
Complete
Marked out of 5.00
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Outline areas that are outside of your expectations of “normal” for Danny within the
framework of your initial systematic assessment (5 marks)? (5 marks)
heart rate 98
nausea
Feedback
Marking here is based on you presenting your results as your Initial Systematic Assessment
(ABCDE assessment). 
•Airway – Recognised A within initial assessment structure AND has recognised nausea as
indications of potential problem (risk) OR sore throat as indications of potential problem
(risk) OR has stated airway is currently patent (Note: you may say nausea as indications of
potential problem (risk) OR sore throat as indications of potential problem (risk) and these would
also be correct. (1 mark).
•Breathing – Recognised B within initial assessment structure AND has recognised maintaining
target saturations but requires oxygen to do this (Scores 2 on NEWS) (1 mark).
•Circulation - Recognised C within initial assessment structure AND has recognised that urine
output is low (outside range of 42.5-85mL/hr expected for Danny), and pulse is elevated from
baseline and weak (1 mark).
•Disability - Recognised D within initial assessment structure AND has recognised that he is
complaining of unmanaged post-operative pain (1 mark)
•Exposure - Recognised E within initial assessment structure AND has recognised that redness
on bridge of nose is indication of pressure damage (1 mark).

If you do not structure your answer in ABCDE assessment format, the maximum marks here you
can get is TWO (recognising all areas of concern from assessment) or ONE (rcognising most
areas of concern from assessment). 

Question 11
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Danny requires oxygen to maintain his target saturation's, which of the following may the
nurse observe as a consequence of this? (1 mark)
Select one:

a. Dry oral mucosa 

b. Oxygen Toxicity
c. Suppression of breathing rate
d. Tiredness
Feedback
Your answer is correct.
The correct answer is: Dry oral mucosa
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Danny’s blood results post operatively were:
 Full Blood Count Us&Es:

White Blood Cells : 7 x109/L Sodium : 130mmol/L

Red cell count (RBC): 4.0 x1012/L Potassium: 4mmol/L
Haematocrit (Hct): 0.35 L/L Urea: 4mmol/L
Haemoglobin: 100g/L Creatinine = 50μmol/L

Question 12
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Based on your understanding of blood results, what is the most likely interpretation of
these results? (1 mark)
Select one:
a. Danny has an infection

b. Danny has anaemia 

c. Danny has hypernatremia
d. Danny has hypokalaemia
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Your answer is correct.
The correct answer is: Danny has anaemia
Question 13
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One of the areas you’re concerned about for Danny is altered body image. Write a
Nursing diagnosis relevant to this care need (2 marks)
due to stoma this create altered body image
Feedback
Remember the structure to write a Nursing Diagnosis. 
<Patients name> is experiencing .... related to .... as evidenced by. 
In this case, 
Danny is experiencing altered body image ... (this has been given to you)
Related to: what do you think the cause of this altered body image is? 
As evidenced by: what part of the assessment supports what you are thinking? 
Example: Danny is experiencing a disturbed body image related to his emergency temporary
Ileostomy as evidenced by inability to look at his ileostomy site.

Question 14
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From the information provided in the case study and your own knowledge present your
prioritisation of care for Danny. Clearly state the top two care needs you have identified
and critically discuss your rationale for their choice. (10 marks)
Nausea 
HB transfusion
Feedback
Danny is acutely unwell and at risk of deterioration. Therefore, the safest way to prioritise care
here is based on his ABCDE assessment. 
Question 15
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Write a patient centred goal for your first prioritised care need. (5 marks)
SMART

Feedback
Remember to based your answer using SMART. Ensure it is Specific, Measurable, Achievable,
Relevant and Timely. 
Example. 
If you were concerned about Danny's Low Circulating Volume an appropriate SMART goal will
be,
Danny will drink (S) 100mL of squash every hour (M & A) to assist managing his fluid volume
depletion (R) which will be reviewed every four hours (T)

If you were concerned about Danny's Pain an appropriate SMART goal will be,
Danny’s pain score (S) will improve to a tolerable level for him of 4(/10) (M & R) over the next 2
hours (T) by increasing analgesia prescribed and administered (A).

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PART 2 - Sally Kowalski is a 72 year old female currently being cared for in
the community
Presenting complaint: The skin integratory around her donor site has started to break
down, there is erythema around the broken down areas of the donor site. A wound swab
indicates Meticillin-Resistant Staphylococcus Aureus (MRSA). She is complaining of
moderate pain at the wound site.
History of presenting complaint: 7 weeks ago Sally sustained a 6% Total Body Surface
Area (TBSA) deep dermal partial thickness burn wound after losing consciousness and
falling into her gas fire at home. A split skin graft was performed and has healed well.
Her fall was associated with hypoglycaemia. In the post-operative period Sally had a
 pulmonary embolism which delayed her recovery and prolonged her time in hospital.
She is now taking warfarin to prevent further blood clots. 
Past medical history: Type 2 Diabetes Mellitus. Pulmonary Embolism.
Social history: Widow.

Question 16
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After the operation Sally’s recovery was delayed by a pulmonary embolism, what clinical
presentation may you expect in someone who has a pulmonary embolism? (1 mark)
Select one:
a. Cough and viscous, purulent sputum green in colour 
b. Dyspnea and reduced chest expansion on affected side
c. Tachypnea and Frothy sputum pink in colour

d. Tachypnea and pleuritic chest pain exacerbated by forceful breathing 

Feedback
Your answer is correct.
We covered PE in both the Post-op care lecture and in the post-op simulations. 
The correct answer is: Tachypnea and pleuritic chest pain exacerbated by forceful breathing
Question 17
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The likely cause of a pulmonary embolism is deep vein thrombosis (DVT), what nursing
care is implemented to reduce the risk of DVTs? (1 mark)

Select one:

a. Give low molecular weight heparin and encourage early mobilisation 

Note: parts of other answers are also correct. However, both parts need to be strategies to
reduce the risk of DVT for the answer to be correct.
b. Give unfractionated heparin and encourage adequate hydration
c. Provide anti-embolism stockings and promote longer fasting times
d. Provide leg exercises and encourage patient to sit in Fowlers position
Feedback
Your answer is correct.
The correct answer is: Give low molecular weight heparin and encourage early mobilisation
Question 18
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 It appears that Sally’s wound may be infected, how might you recognise an infected
wound? (1 mark)
Select one:
a. Cellulitis and malodour
b. Clear exudate and necrotic tissue
c. Granulating wound and  oedema

d. Over-granualtion and pain 

Note: parts of other answers are also correct. However, both parts need to be typical local signs
of infection for the answer to be correct.
Feedback
Your answer is incorrect.
The correct answer is: Cellulitis and malodour
Question 19
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One strategy to help confirm the diagnosis of an infection is to take bloods. If the nurse
took bloods from Sally, what result would support the diagnosis that Sally had an
infection? 
Select one:
a. Elevated Creatine
b. Elevated Haemoglobin

c. Elevated Leucocytes 
d. Elevated Potassium
Feedback
Your answer is correct.
The correct answer is: Elevated Leucocytes
Question 20
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What signs, available in the community, may indicate that a wound infection has become
sepsis? (1 mark)
Select one:

a. Increased heart rate, altered mental state,  decrease or increase in temperature 

b. Increased respiratory rate, Meningitis, Urine infection
c. Lactate above 2mmol/L, cyanosis of the skin, increased urine output
d. Redness, Swelling, Pain
Feedback
Your answer is correct.
The correct answer is: Increased heart rate, altered mental state,  decrease or increase in
temperature
Question 21
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If a patient is showing systemic signs of infection, the GP may want to prescribe oral
antibiotics. Which of the following is NOT part of the Registered Nurses’ role in
antimicrobial stewardship? (1 mark) 
Select one:
a. Ensure that diagnostic samples are obtained, labelled clearly and sent promptly to the
microbiology laboratory

b. Ensure that patients stop taking their antibiotics as soon as they feel better  
c. Highlight prescriptions that do not comply with local policy with the prescriber and/or pharmacist
d. Maintain optimal infection prevention and control practice.
Feedback
Your answer is correct.
The correct answer is: Ensure that patients stop taking their antibiotics as soon as they feel
better 
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Current medications: Metformin (500mg BD). Warfarin 3mg/day. Her last INR was 2.5
(target INR 2-3). Dose has remained stable since discharge from hospital.

Question 22
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Sally is taking warfarin, what are the potential side effects of taking warfarin? (1 mark)
Select one:
a. Increased risk of deep vein thrombosis (DVT)

b. Increased risk of excessive bleeding 

c. Increased risk of infection
d. Increased risk of myocardial infarction
Feedback
Your answer is correct.
The correct answer is: Increased risk of excessive bleeding
Question 23
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Sally has Type 2 diabetes, what impact does raised blood glucose have on wound
healing? (1 mark)
Select one:
a. Increases energy available for wound healing
b. Increases risk of hypertrophic scaring
c. Increases risk of over-granulation 

d. Increases risk of wound infection  

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Your answer is correct.
The correct answer is: Increases risk of wound infection 
Question 24
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You have just started your day shift and go to Sally’s estate. Sally lives within a few
minutes’ walk of three other patients; Mrs Abrahams is a new patient you haven’t met
before and requires bloods, nursing assessment and a wound dressing on her left leg;
Mr Smithsonian is a patient with Diabetes Mellitus Type 2 on once/day insulin who
received his insulin yesterday at 8.00 a.m; Mrs Thompson is a palliative care patient with
a fungating wound a morphine syringe driver insitu).  
While prioritising care, who would be the best person to see first? (1 mark) 

Select one:
a. Mrs Joan Abrahams (New patient with lower leg wound) 
b. Mrs Sally Kowalski (Breakdown of donor site)
c. Mr Adam Smithsonian (patient on once/day insulin) 
d. Mrs Mary Thompson (Palliative care patient with fungating wound and morphine syringe

driver insitu)  
Feedback
Your answer is incorrect.
You have 4 patients you can chose from here. 
Remember to prioritize which patient you are going to see, 
(1) Based on ABCDE assessment
For these patients, 
Mrs Joan Abrahams (New patient with lower leg wound) = E
Mrs Sally Kowalski (Breakdown of donor site) = E

Mr Adam Smithsonian (patient on once/day insulin) = D

Mrs Mary Thompson (Palliative care patient with fungating wound and morphine syringe
driver insitu) = D & E 

(2) If this is still unclear, consider whether there is anything that is time sensitive here. 
In this case, it would be better to see the patient on once-per-day insulin at the same time as the
previous day. 
The correct answer is: Mr Adam Smithsonian (patient on once/day insulin) 
Question 25
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When you arrive at Sally's house, she complains of pain at her donor site, which of the
following may the nurse observe as a consequence of this?
Select one:
a. Bradycardia and decreasing depth of breathing

b. Hypertension and bradypnea 

c. Increased peripheral resistance and increased depth of breathing
d. Tachycardia and Tachypnea
Feedback
Your answer is incorrect.
The correct answer is: Tachycardia and Tachypnea
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On examination of Sally:
Ø  Cardiovascular System: HR = 91, BP = 130/78, warm to touch
Ø  Central Nervous System: Alert, Orientated to Time, Place and Location.
Ø  Gastrointestinal system and Renal System: Poor oral intake since death of husband.
Declares she frequently skips meals. Passed urine approximately 2 hours ago states
good amount
Ø  Musculoskeletal and Integumentary System: Impaired confidence and reported fear in
mobilising following her recent fall. States she currently moves slowly around the house
when she needs to but, isn’t confident going outside or walk upstairs. Pressure areas
intact. Non-blanching erythema on her sacrum. The skin integratory around her donor
site has started to break down, there is erythema around the broken down areas of the
donor site. A wound swab indicates Meticillin-Resistant Staphylococcus Aureus (MRSA).
She is complaining of moderate pain at the wound site.
Ø  Respiratory System: RR = 21, SpO2 = 98% on room air, No use of accessory
muscles, No decreased depth of breathing, No signs of central or peripheral cyanosis.
Sputum = Clear/Watery
Ø  Other - Endocrine System, Reproductive System, Immune System:  temperature
37.6’C, blood sugar = 4mmol/L

Question 26
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Outline areas that are outside of your expectations of “normal” for Sally within the
framework of your initial systematic assessment (5 marks)
HEArt rate
poor oral intake
 lack of mobilisation/ anxiety
skin not intact
infection

Feedback
Remember this should be structured in the form of your Initial Systematic Assessment (ABCDE)
to get the full 5 marks, 
•Airway – Recognised A within initial assessment structure AND has recognised that this is
normal (1 mark).
•Breathing  – Recognised B within initial assessment structure AND has recognised respiratory
rate is elevated (1 mark).
•Circulation - Recognised C within initial assessment structure AND has recognised heart rate is
elevated / temperature is borderline high* (1 mark).
•Disability - Recognised D within initial assessment structure AND has recognised that her blood
sugar is borderline low (1 mark)
•Exposure - Recognised E within initial assessment structure AND has recognised that non-
blanching redness on sacrum is category 1 pressure ulcer OR  Wound breakdown and Meticillin-
Resistant Staphylococcus Aureus (MRSA) in donor site, / temperature is borderline high * (1
mark).
•
(Note: abnormal temperature sometimes considered under C or E, depending on where you
read. Therefore, can get mark for including this in either C or E)
If you have not structured in ABCDE format, the maximum marks you can get here is TWO. 
Question 27
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You are concerned that Sally is not eating a balanced diet, what foods would you
encourage to promote wound healing? 
Select one:
a. Foods containing vitamin B such as fish and fatty foods such as chips
b. Fibre rich foods such as brown rice and foods containing glucosamine such as shellfish

c. Protein dense foods such as nuts and foods containing vitamin C such as citrus fruits.  
d. Zinc dense foods such as Leafy vegetables and foods containing lots of sugar such as fizzy drinks
Feedback
Your answer is correct.
The correct answer is: Protein dense foods such as nuts and foods containing vitamin C such as
citrus fruits. 
Question 28
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One of the areas you’re concerned about for Sally is her reduced mobility following her
recent fall. Write a Nursing diagnosis relevant to this care need. (2 marks)
lack of mobilisation cause skin problems and poor healing refer to physio
Feedback
Remember the structure how to write a nursing diagnosis. 
Patient is experiencing disturbed body image (given within the question) related to/caused
by .....as evidenced by....

Question 29
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From the information provided in the case study and your own knowledge present your
prioritisation of care for Sally. Clearly state the top two care needs you have identified
and critically discuss your rationale for their choice. (10 marks)
infection
skin
Feedback
As Sally is at risk of deteriorating and our aim to maintain function and health, structure your
answer based on ABCDE. 
Question 30
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Write a patient centered goal for your first prioritised care need. (5 marks)
physio input
antibiotics review in 72 hr aim to complete
Feedback
Remember to based your answer using SMART. Ensure it is Specific, Measurable, Achievable,
Relevant and Timely.