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HLTENN011 Implement & Monitor Care for a person with Acute Health Problems
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[this assessment]
? Demonstration simulation lab (Tollefson activities)
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Student Instructions
Read each question carefully after having accessed and viewed the case study on the website. In order to be deemed Satisfactory in this compulsory assessment task you must answer ALL the numbered questions below. Write/type answers in the fields provided. This assessment requires a response to short answer questions; multiple choice; true false and case study/ clinical scenario responses. These can be typed and dot points can be used. This must be undertaken by you. You are able to use your study notes to assist you with completing your answers. If you do not receive a ‘Satisfactory’ result (NYS) you may be provided with an alternative supplementary assessment.
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Access the case study via the YouTube on the internet. In response to this you will need to provide answers to the 10 questions below. Please respond in simple short answers of no more than 4 sentences.
Elizabeth Scarr had already suffered one heart attack, and when she began to experience neck and shoulder pain some time later, was diagnosed with unstable angina and admitted to hospital.
1. What were the signs and symptoms that Elizabeth describes?
2. What is unstable Angina
3. What assessments would be undertaken for unstable Angina?
4. Detail the nursing management of the patient that presents with acute Unstable Angina that is experiencing chest pain.
5. With Angina describe how the heart is affected during the symptoms Elizabeth describes?

6. What are the risk factors for Angina or Heart Attacks?
7. What education can you provide to patients upon discharge on healthy points for a healthy heart?
8. What tests / investigationsmay the patient require post an unstable angina event?
9. What could these tests show about this patient?
10. What psychological supports and care could be required for this patient with unstable angina?

Emergency Management
1. Define the following terms and or abbreviations
Cardiac Arrest:
Respiratory Arrest:
2. In an emergency situation it is important to assess the situation quickly and efficiently to ensure the safety of you, the patient and others in the vicinity. Complete the following BLS assessment flowchart.
Name the keywords that outline the process that should be followed in an emergency situation.
3. List 4 potential /actual hazards when managing a code blue in the hospital environment.
4. Describe 2 ways you would assess for ‘Response’
5. If your patient does not respond to you after the above methods have been attempted, what should your next action be?
(Please circle the correct response)
a) Panic
b) Run from the room and call for help
c) Stay with the patient and call for help
d) Assess the patients airway
6. Maintaining a patent airway is vital in an emergency situation. Under the following headings outline how you would achieve this
Assess their airway - include patient position/safety
Clearing the airway
Maintaininga patent/clear airway
7. If the patient’s airway is not threatened by the presence of vomitus, blood or foreign bodies, is it necessary to position the patient on their side to inspect and clear the airway.
8. Using the following headings, briefly outline how you would make your assessments to ascertain whether your patient was breathing.

9. If after you have assessed your patient and found them to be breathing circle all the actions would you take?
(Please circle the correct response/s)
A. Leave the patient on their back and support them
B. Roll the patient into the recovery position
C. Place oxygen on the patient via a Hudson mask
D. Undertake general observations and conscious state
E. Sit the patient upright and place oxygen on them via nasal prongs
F. Apply the leads to monitor the patient’s rhythm
10. If you have assessed your patient as not breathing what should be undertaken at this time?
(Please circle the correct response)
A. Give 5 quick breaths via the bag or mask and check for pulse
B. Give 2 quick breaths via the bag or mask and check for pulse
C. Start CPR
D. Place oxygen on the patient via a Hudson mask
11. When checking for pulse which pulse would you locate and use:
Circle the correct answer
a) Radial pulse
b) Popliteal Pulse
c) Brachial Pulse
d) Carotid Pulse
How long would you take to confirm presence or absence of a pulse?
(Please circle the correct response)
a) 2 sec.
b) 5 sec.
c) 5-10 sec.
d) 10 -15secs.

12. If your patient is breathing and has a pulse but you are required to monitor the patient. How should the electrodes be applied?
(Please circle the correct response)
a. Black – Right arm White - Left arm Red – Left Leg
b. Black – Left arm White - Left leg Red – Right Arm
c. Black – Left Arm White - Right arm Red – Left Leg
d. Black – Left Leg White - Left arm Red – Left Arm
13. If you have assessed the patient as having no pulse and is not breathing what action should you commence first?
(Please circle the correct response)
a. Apply the gel pads and turn on the SAED
b. Perform a full minute cycle of CPR – 1 breath to 5 compression ratio
c. Perform 30 compressions followed by 2 ventilations
d. Perform a full two minute of CPR at a rate of 30 compressions to 2 ventilations
14. What is the correct location to use on the sternum when undertaking cardiac compressions?
(Please circle the correct response)
a. Upper third of the sternum
b. Middle third of the sternum
c. Lower third of the sternum
d. Over the Xyphoid process
15. What is the correct depth to achieve to deliver effective cardiac compressions?
(Please circle the correct response)
a. One quarter of the chest wall
b. One third of the chest wall
c. One half of the chest wall
d. As far as you can go

16. In what three circumstances can the SAED gel pads be placed on the patient?
17. When positioning the pads it is important to:
Circle the correct response/s
a) Ensure pads are not placed over the sternum
b) Pads are placed in the anterior lateral position
c) That pads are applied using a rolling motion to avoid air trapping between skin and pads
d) wipe away any moisture, creams or ointments from the chest
e) do not place over ECG dots
f) Do not place over a pacemaker
g) do not place pads on if they are touching/overlapping
h) all of the above
18. Should oxygen be removed away from the patient and the electrodes prior to pushing the shock button?
19. How can potential or possible causes of chest and other body burns be minimized/eliminated when using the life Pak 12/20?
Circle the correct response/s
a) pads must be applied in a rolling motion
b) chest wall must be clean, bare and dry
c) ensure that the patient is not touching any metal
d) Ensures air is not trapped under the electrodes
e) clip chest hair if the patient is hairy
f) Pads should not be touching or overlapping
g) All of the above
20. What is the ventilation to compression ratio for the following situations?
(Circle the correct response)
Single person CPR
a) 1 - 5
b) 1 - 10
c) 2 - 15
d) 2 - 30
Dual person CPR
a) 1 - 5
b) 1 - 10
c) 2 - 15
d) 2 - 30
21. What is the recommended depth of compressions for all ages?
(Please circle the correct response)

a) 5cm
b) 10cm
c) one third of the chest cavity to a max. of 4-5 cm in an adult
d) 2/3 of the chest cavity to a max. of 4-5 cm in an adult
22. How long should the first round of CPR continue before ROSC is checked?
(Please circle the correct response)

a) 1 minute
b) 2 minutes
c) 3 minutes
d) 30 seconds

23. What types of ventilation devices can be used in a code blue event?
(Please circle the 2 correct responses)
a) Pocket Face Mask
b) Air viva
c) Oxygen mask
d) Mouth to mouth resuscitation
24. List the common causes of unconsciousness under the following headings:
Blood Oxygenation Problems
Metabolic Problems
Blood Circulation Problems
Central Nervous problems
25. A MET call is used to identify a potentially deteriorating patient. Outline the changes to the patient’s condition that may indicate that they are deteriorating and that you need to call a MET call.

26. From the list below, place the appropriate roles that each of the emergency response team may be involved in during an emergency situation.
A. Basic Airway Management
B. Attach defibrillator Pads
C. Basic Life Support – CPR
D. Prepare 1st line – Advanced Life Support (ALS) Medications
E. Administer ALS medications
F. Defibrillate the patient
G. Scribing
H. Scout – gather or find equipment
I. Advanced airway management
Medical Officer
Senior RN (ALS)
Ward RN / EN
27. List the emergency equipment that must be checked on the resuscitation trolley
28. List the emergency equipment that must be checked at the bedside.

1. Which of the following are common forms of traction?
Circle the correct response:
1. Simple Buck’s Traction
2. Manual Traction
3. Plaster of Paris
4. Hamilton Russell Traction
5. Skeletal Traction
6. All of the above
2. What are the indications for traction?
3. What equipment is necessary to apply non-adhesive skin traction?
4. How can counter traction be accomplished in the clinical setting?
Please circle the appropriate response:
? Trendelenberg tilt the foot of the bed upwards
? Raise the head of the bed only
? Raise the foot of the bed only
? Keep the bed flat
5. When applying non-adhesive skin traction should the bandage be applied above the knee?

6. If the bandage supplied with the traction kit is soiled can a crepe bandage be substituted?
7. When applying the traction apparatus should the footboard be placed very close or against the patient’s foot?
8. You are caring for a patient with a fracture shaft of femur who is in 6 pounds of non-adhesive skin traction. Describe the necessary nursing observations under the following headings:
? Patient observations and assessment
? Skin integrity

9. When skin traction is applied the management of the apparatus is essential to maintain even, balanced traction. Answer the following by choosing the correct response/s:
a. Which of the following aspects should apply to the ropes connecting the traction to the weight bag?
? No weight applied directly onto the ropes
? Ropes free from knots and twists
? Frayed ropes should be discarded & changed
? All of the above
b. Which of the following aspects should apply to the weight bag?
? Weight bag should hang cleanly above the floor
? Water or sand can be used to fill the bag
? No more than 8 pounds should be applied
? If there is a hole in the bag it can be patched up with sleek
? All of the above
c. Which of the following aspects should apply to the pulleys?
? Pulley should run in a straight line from the leg to the bed
? Pulleys should allow the ropes to run freely
? All of the above
10. How frequently should skin traction be removed?
Circle the correct response:
? Once a day
? Once per shift
? Should remain intact
? Every 2 days

11. When applying skin traction what position should the patient be in?

? On their side
? Supine
? Semi upright
? With counter traction applied
12. When applying the bandage to secure skin traction how should it be applied?
Circle the correct response:
? Circular application
? Figure of eight application
? Requires more than one bandage
? Spiral application
13. When attending to neurovascular observations, should they be performed on the affected limb only or should they be performed on both the affected and non-affected limbs? Why?
14. What are the complications associated with the application of traction?
15. Is a medical order required to apply skin traction and should the exact weight to be applied be documented by the Medical Officer?

16. The common perineal nerve is close to the surface in certain areas of the lower leg. Which particular areas should be covered with soft padding or avoided when bandaging? Circle the appropriate response/s:
? Malleoli
? Head of the fibula – lateral aspect
? Patella
? All of the above
17. Should the footboard of the traction apparatus always be clear from the foot of the bed?

Pre &Post Operative Management
Your patient Mr Smith has been admitted electively to undergo an Open Cholecystectomy for impacted gallstones. You are the nurse that is responsible for admitting the patient and preparing them for theatre.
1. List all the requirements that must be undertaken to ensure that this patient is fully prepared for theatre. There are sub headings to help you to ensure all areas have been completed.
Patient Preparation
Things to send to Theatre
2. Another one of your patients is returning from theatre after having a spinal anaesthetic. What is a spinal anaesthetic and what nursing observations must be undertaken on your patient who has undergone a spinal anaesthetic?
3. What are your responsibilities to prepare the patient environment for your patient returning from theatre?
4. Before bringing your patient back to the ward you must receive handover of your patient from the recovery nurse. What information must you ensure that you receive during this handover?

5. On return to ward (RTW) – your patient is complaining of pain. What post-operative comfort strategies could you consider to provide adequate pain management for your patient?
6. Your patient Mr. Smith has returned from theatre after having the open cholecystectomy under general anesthetic. He will return with the following:
• Drain tube
• Abdominal dressing
• IV therapy with Hartman’s running 6 hourly
• Oxygen therapy via Hudson mask at 6 lit/min
• IDC in-situ
• Post operative orders
- nil by mouth - maintain oxygen therapy for 24 hours - rest in bed until fully awake
Using the table below to help you, outline all the post operative care and management that you will undertake for this patient on their return to the ward post operatively.
Nursing Care and/or
Systems Type of Assessment/s
Devices to Assess Nursing Care &Management Frequency Rationale
Patient Observations
Skin / Integument
Fluid management
Input & Output
Pain Management
Pressure Area management
Main Safe Environment
Respiratory / Airway
6. List 5 common post-operative complications that you could be expected for Mr Smith in the immediate postoperative period?
7. Define the following surgical terms
A. Local Anaesthetic
B. Spinal Anaesthetic
C. Caudal Block

D. Epidural Analgesia
E. Peripheral Nerve Block
8. Explain then following surgical terminology
A. Amputation
B. Open reduction
C. Hip replacement
D. Craniotomy
E. Tonsillectomy
F. Appendectomy
G. Laparotomy

H. Hysterectomy
I. Prostatectomy
J. Cataract extraction
Question 9
Outline the signs and symptoms that may indicate internal bleeding in your patient that presents after surgery from a major trauma.

1. Outline the following common respiratory terminology.
• Dyspnoea
• Tachycardia
• Tachypnoea
• Wheeze
• Cyanosis
• Dysphagia
• Pyrexia
2. Your patient suddenly has difficulty breathing and has become short of breath. Outline the important nursing care that you will undertake to assess and manage this patient.
3. Outline the important aspects of oxygen therapy. Include safety aspects and monitoring of your patient.
4. What are the acceptable oxygen flow rates to be used when administering oxygen via the following types of masks?
Nasal prongs:
Hudson Mask:
5. What fluid type should be utilised in the humidification systems?
Circle the correct response:
• Sterile Water
• Normal Saline
• Fresh Water
• 5% Dextros
6. When delivering nebulisation therapy to your patients what type of gas flow should the nebuliser mask be connected to?
Circle the correct response:
Patient with no COPD History
• Oxygen
• Air
• Does not matter
Patient with a known COPD History (CO2 Retainer)
• Oxygen
• Air
• Does not matter
7. You are required to administer nebulisation therapy to your patient. What is the best position for administration?
Circle the appropriate response:
Patient position:
• Lateral
• Sitting upright
• Supine
• Semi upright
8. After completion of the nebulisation therapy what should the nurse instruct the patient to perform?
9. Which of the following is an early indicator that a patient’s oxygen levels in their blood may be reduced or inadequate?
Circle the correct response:
10. Define the following terms
? Pneumothorax
? Haemothorax
? Empyema

11. Your patient has been admitted to hospital with a suspected pneumothorax. Outline the normal sites for insertion of intercostal catheters in the following situations:
12. After having a chest x-ray performed the pneumothorax has been identified. An ICC has been inserted and connected to an UWSD bottle system. Describe the function of the following components on the underwater seal drainage system under the following headings.
Underwater seal chamber
Suction control chamber
Drainage chamber
13. What observations must the nurse perform when caring for the patient with an underwater seal drainage bottle? Use the following headings
The Patient
14. The position that the UWSD system should be kept in an upright position and always below the level of the chest.
15. In what chamber would an air leak be observed?
Circle the correct answer
? Suction control chamber
? Water seal chamber
? Drainage chamber
16. What chamber would you be able to identify a swing?
Circle the correct answer.
? Suction control chamber
? Water seal chamber
? Drainage chamber
17. When assessing the underwater seal system you note that there is NO swing present. What might this indicate?
18. Define the following terms:
19. To commence CPAP therapy in the ward setting is it necessary for the medical officer to prescribe a particular level of PEEP?
20. List the 3 common indications for CPAP therapy
21. When would CPAP therapy be contraindicated for a patient?
22. If your patient has labile blood pressure can the application of CPAP therapy further drop their blood pressure?
23. Your patient has been admitted with pneumonia. What psychological supports and care could be required due to the impact of their acute respiratory condition?

Clinical Scenario 1
Gary is a 45 year old male. He presented to the emergency department after a fall from a first floor window last night. He had been out drinking at a work function and had forgotten his house keys. His wife called an ambulance this morning as Gary was very agitated and appeared to have a weakness in his left arm and leg. She also noticed some blood loss on the pillow from a gash on Gary’s head.
Using the headings below, state how you this patient will be managed.
a. What do you think has happened to Gary? What condition may he have sustained?
b. What assessments will you undertake on Gary considering your initial thoughts on his potential condition?
c. You are required to undertake neurological observations. How will you ask the questions to complete a correct Glasgow Coma Scale for Gary and what does this involve? Give examples of your questions.
d. What complications may occur from the injury that Gary presents with?

Clinical Scenario 2
Mr Ken Nyugen is a 56 year old male who has been admitted to the acute medical ward with an ischaemic stroke. He initially presented by ambulance after being found slumped in a chair at home by his daughter. On initial presentation to the emergency department the following assessment data was obtained:
GCS 11/15
PEARL 4 pupils equal and reactive to light
RR 20
BP 210/100
HR 50 Regular
12 lead ECG Right Bundle Branch Block – old
SpO2 92% RA
Course crackles right lower lobe
T 37.5
Left hemiplegia
a. Detail how you would perform your physical assessment of the client.
b. What is Mr. Nguyen’s main risk factor that may have contributed to this CVA?
c. Explain the different causes or types of CVA.

d. What are some of the other risk factors of Stroke
e. What is dysphagia?
f. What are some indications of dysphagia?
g. Explain the nursing management for Mr. Nguyen in the acute setting? What care interventions will be required?
End of Assignment