Question Set B: Matrix, Drop-Down, and Bowtie at the Bedside
Three narrow scoring panels showing the same six-cell response pattern resolving three ways: per-row credit, a bracketed dyad emptied by one wrong cell, and an all-or-none pattern collapsing to a single empty box.
Item 7 · Matrix An adult is on the first day after tracheostomy placement and has a documented sacral skin change. Classify each finding as expected, requires monitoring, or requires immediate follow-up. One response per row.
| # | Finding |
|---|---|
| 1 | The tracheostomy stoma is pink to red with a small amount of serosanguineous drainage. |
| 2 | Oxygen saturation falls during a suction pass and does not return toward baseline after the catheter is withdrawn and the patient is reoxygenated. |
| 3 | Non-blanchable deep red discoloration of intact skin at the left index finger under the pulse oximetry probe. |
| 4 | The blood pressure cuff used this shift is one size smaller than the cuff documented on the previous two shifts. |
| 5 | An obturator, a spare tube of the same size, and a spare one size smaller are at the bedside. |
| 6 | The sacral area shows partial-thickness loss with a viable pink moist bed and no slough. |
| 7 | Audible gurgling with rising work of breathing. |
| 8 | A precut gauze dressing sits under the tracheostomy flange. |
Item 8 · Drop-down cloze Complete the two sentences.
When assessing this patient's abdomen the nurse first [1], then [2], then percusses, then palpates lightly. Because the previous shift's bowel sound entry was recorded after palpation, the nurse [3] and documents the [4].
- [1] inspects the contour and skin · auscultates all four quadrants · palpates lightly · percusses for tympany
- [2] auscultates all four quadrants beginning at the right lower quadrant · palpates deeply in each quadrant · measures abdominal girth · percusses the liver border
- [3] accepts the documented finding as the baseline · regenerates the finding in the correct sequence · reports the documented finding to the provider · repeats palpation to confirm it
- [4] new finding as a conclusion about bowel function · nurse's interpretation of the sounds heard · new finding as an observation with the time it was obtained · discrepancy as an error made by the previous nurse
Item 9 · Bowtie An adult has a nasogastric tube placed at the bedside and an order to begin feeding. The chart contains no documented confirmation of tip position. Select the condition, two actions, and two parameters to monitor.
Condition: unconfirmed nasogastric tube tip position.
Actions to take, choose two: withhold the feeding · obtain radiographic confirmation of tip position · begin the feeding at a low rate and observe · instill an air bolus and auscultate over the epigastrium · advance the tube two inches and retry.
Parameters to monitor, choose two: respiratory status including work of breathing and oxygen saturation · exposed tube length against the documented insertion mark · bowel sounds every hour · daily weight · urine specific gravity.
Condensed rationales
Item 7 — Answers: 1 expected · 2 immediate follow-up · 3 immediate follow-up · 4 requires monitoring · 5 expected · 6 requires monitoring · 7 immediate follow-up · 8 expected. Why these: a pink stoma with light serosanguineous drainage on day one is normal healing, and precut gauze with a full spare set at the bedside is correct practice. A saturation that does not recover after a pass means the pass caused harm and the airway needs attention now. Non-blanchable discoloration under a device is a device-related pressure injury and the device is moved immediately. Gurgling with rising work of breathing is the indication to suction now. A cuff change invalidates the trend and calls for remeasurement by the documented method, which is monitoring rather than emergency. A Stage 2 sacral wound needs a plan and reassessment, not a call. Most attractive wrong answer: classifying row 4 as immediate follow-up. It is a data quality problem, not a physiologic one. Scoring: per-cell. Every row scores independently, so an unanswered row is a guaranteed loss and a reasoned answer costs nothing.
Item 8 — Answers: [1] inspects the contour and skin · [2] auscultates all four quadrants beginning at the right lower quadrant · [3] regenerates the finding in the correct sequence · [4] new finding as an observation with the time it was obtained. Why these: the abdominal order is inspect, auscultate, percuss, palpate, and a sound recorded after palpation is not usable. The regenerated finding is charted as an observation with its time, not as a conclusion and not as a complaint about a colleague. Most attractive wrong answer: reporting the documented finding to the provider at [3]. It feels responsive, but it passes on a finding that was never valid. Scoring: per-response. Each drop-down is scored separately.
Item 9 — Answers: actions, withhold the feeding and obtain radiographic confirmation · parameters, respiratory status and exposed tube length against the documented mark. Why these: nothing goes down an unconfirmed tube. Confirmation is radiographic, and the two things worth watching are whether the airway is involved and whether the tube has moved. Most attractive wrong answer: instilling an air bolus and auscultating. It is the method many candidates were taught, and it is not acceptable. Scoring: all-or-none within each wing on most published bowtie models, so one wrong selection in a wing empties that wing.
Margin notepartial credit means never leave a row blank.
TakeawayScoring differs by format, so a reasoned answer in every cell beats a confident guess in one.
How to read a next-generation case → BOOK 01 · P60.