The Work Bench · Registered Nurses

Modify treatment plans

The task, from O*NET: Modify patient treatment plans as indicated by patients' responses and conditions.

Typical length 25 minutes. Time split: documents 70%, systems 30%. About 128,582,394 hours a year of desk work across the US go to this task.

Passes, one attempt by Claude Fable 5.1. The rubric was written 2026-10-01 03:42 UTC, before the attempt (2026-10-01 03:50 UTC); the grade came last (2026-10-01 03:54 UTC).

One attempt at one task on one date, with constructed material: it is not a statement that the job, or this task in a given workplace, can be done by AI. The rubric, the attempt and the grade were made by the same model in one session, in that order; a person's check of a sample of grades will be published beside them.

The brief

You are the registered nurse on an orthopedic unit at Harbor Street General, caring for a constructed patient on post-operative day 2 after a right total knee replacement. Using the orders, the current nursing care plan, the standing protocol and the patient's responses over the last 24 hours, write the modifications to the nursing care plan: which interventions change and how, which stay, what you do now under the protocol, and what you escalate to the surgeon as an SBAR. Stay within nursing scope: modify nursing interventions and apply the protocol; do not change medical orders yourself, and do not invent anything about the patient.

The material

Constructed for this example; the names, figures and documents are invented.

PATIENT (constructed): Robert Anand, 66, right total knee replacement two days ago.

ORDERS: oxycodone 5 mg by mouth every 4 hours as needed for pain 4 to 6, 10 mg for pain 7 to 10; acetaminophen 1 g every 6 hours scheduled; enoxaparin 40 mg subcutaneous daily; physical therapy twice daily, weight-bearing as tolerated; incentive spirometer 10 times an hour while awake; diet as tolerated; discharge planned post-operative day 3 if walking 150 feet with a walker and pain controlled.

CURRENT NURSING CARE PLAN: pain goal 3 or less at rest, 5 or less with activity; walk with the walker three times a day with PT and nursing; ice to the knee 20 minutes after therapy; dressing checked every shift, dry and intact; bowel regimen senna nightly; sleep protected by grouping overnight care.

RESPONSES, LAST 24 HOURS: pain 7 to 8 during PT sessions despite oxycodone 5 mg given 45 minutes before; pain 4 at rest. Refused the afternoon PT session yesterday because of pain and nausea after the morning dose. Nausea after oxycodone twice; vomited once; ate 25% of meals. No bowel movement since surgery. Incentive spirometer used 3 to 4 times an hour; SpO2 94% on room air, 92% during sleep last night; lungs diminished at the bases, no crackles. Temperature 37.9 last evening, 37.4 this morning. Dressing with a quarter-size spot of serosanguineous drainage, unchanged from yesterday. Calf soft, no tenderness. Walked 60 feet with the walker this morning, stopping twice. The patient says: "I'm not going home tomorrow like this."

STANDING PROTOCOL (excerpt)
- Nausea with opioids: the nurse may give ondansetron 4 mg by mouth or IV every 8 hours as needed per the post-operative order set (it is in this patient's set); notify the surgeon if vomiting persists past two episodes or the patient cannot keep down oral medication.
- Pain above goal on two consecutive assessments despite the ordered medication: notify the surgeon for order review; the nurse may adjust the timing of ordered doses before therapy within the order's limits and add non-drug measures.
- No bowel movement by post-operative day 2 on opioids: the nurse may give the ordered bowel regimen plus bisacodyl 10 mg suppository once per the order set; notify if no result by day 3.
- SpO2 below 92% sustained, or incentive spirometer use below 6 times an hour: increase coaching, reposition, notify if below 90%.
- Temperature above 38.3: notify.
- Drainage: notify if increasing, purulent or soaking the dressing.

The rubric, written before the attempt

1. Each response is matched to a care plan change or a protocol action. Evidence: Pain: the ordered doses timed before PT within the order's limits, acetaminophen kept on schedule, non-drug measures added, the surgeon notified for review after two above-goal assessments. Nausea: ondansetron per the order set before the opioid, the surgeon notified if vomiting continues. Bowels: senna plus the bisacodyl suppository per the order set. Breathing: spirometer coaching toward 10 an hour, repositioning, walking. Mobility: shorter, more frequent walks with pre-medication.
2. Protocol limits are respected. Evidence: No drug or dose outside the order set; the 10 mg dose used only as the order allows (pain 7 to 10), not made routine; medical order changes requested from the surgeon, not made.
3. Thresholds are applied correctly. Evidence: 37.9 and 37.4 do not meet 38.3; 92% in sleep is not below 92% sustained, so coach and monitor with notification below 90%; drainage unchanged, so checks continue; the calf finding recorded as normal.
4. What stays is stated, so the plan is whole. Evidence: Dressing checks, ice after therapy, sleep protection and the enoxaparin named as unchanged.
5. The SBAR to the surgeon is complete and factual. Evidence: Pain above goal with PT despite medication, nausea and one vomiting episode, intake at 25%, 60 feet against the 150-foot discharge criterion, the patient's own words, and a request for order review and discharge planning, without a diagnosis.
6. Scope and honesty. Evidence: Nursing interventions only; nothing invented about the patient (no new vitals, no assumed intake or bowel result); the refusal of therapy addressed rather than overridden.

The attempt, one pass, unedited

Claude Fable 5.1, written 2026-10-01 03:50 UTC from the brief and the material only.

CARE PLAN MODIFICATIONS, post-operative day 2, R. Anand, right total knee replacement

What changes, and why
1. Pain with therapy (7 to 8 during PT despite oxycodone 5 mg given 45 minutes before; 4 at rest). Pain has been above the activity goal on consecutive assessments despite the ordered medication, so the surgeon is notified for order review (SBAR below). Within the current orders: time the scheduled acetaminophen so a dose falls about an hour before each PT session; at the pre-therapy assessment give the oxycodone dose the pain score calls for under the order (5 mg for 4 to 6, 10 mg for 7 to 10), 45 to 60 minutes before therapy; add ice to the knee for 20 minutes before therapy as well as after; use repositioning and elevation between sessions. Reassess pain 30 minutes after each dose and at the start of therapy.
2. Nausea and vomiting after oxycodone (nausea twice, one vomiting episode, intake 25% of meals). Per the order set, give ondansetron 4 mg about 30 minutes before the oxycodone dose, and give the oxycodone with food. Offer small, frequent meals and fluids. The surgeon is notified if vomiting passes two episodes or he cannot keep oral medication down; one episode so far.
3. No bowel movement since surgery, on opioids, day 2. Continue senna tonight and give the bisacodyl 10 mg suppository once today per the order set; encourage fluids and walking; notify if no result by day 3.
4. Breathing (spirometer 3 to 4 times an hour against the ordered 10; SpO2 94% awake and 92% in sleep; bases diminished, no crackles). Increase coaching: an hourly target with the spirometer at the bedside, use checked each hour, repositioning (head of bed up, side to side), spirometer use tied to each walk. 92% in sleep does not meet the protocol's sustained-below-92 line; continue to monitor and notify if below 90%.
5. Mobility (60 feet this morning with two stops; the afternoon PT session refused; the discharge criterion is 150 feet). Replace the three longer walks with shorter, more frequent ones: PT twice daily, plus nursing-led walks of 30 to 50 feet two or three times, each pre-medicated as above and timed away from nausea. Record the distance each time.
6. The patient's own words, "I'm not going home tomorrow like this," are reported to the surgeon and to physical therapy. Discharge timing is their call; the plan supports whichever day it is.

What stays
- Dressing checks every shift: the quarter-size serosanguineous spot is unchanged, not increasing, purulent or soaking, so no notification; continue.
- Ice after therapy; sleep protected by grouping overnight care.
- Enoxaparin 40 mg daily continues as ordered.
- Temperature 37.9 last evening and 37.4 this morning are below the 38.3 line; routine monitoring continues.
- Calf soft and non-tender: recorded; daily checks continue.

What I did now under the protocol
- Ondansetron 4 mg given before the next oxycodone dose per the order set, at [time].
- Bisacodyl 10 mg suppository given per the order set, at [time].
- Spirometer coaching and hourly checks started; head of bed raised.
- Pain medication timing adjusted for this afternoon's PT; PT told the session will follow the pre-medication.

SBAR to the surgeon, [time]
Situation: Mr. Anand, post-op day 2 right TKR, has pain 7 to 8 with PT despite oxycodone 5 mg given 45 minutes before (4 at rest), nausea twice and one vomiting episode after oxycodone, intake 25% of meals, no bowel movement since surgery, and walked 60 feet this morning with two stops; he refused yesterday's afternoon session. He says he is not going home tomorrow like this.
Background: TKR two days ago; orders are oxycodone 5 or 10 mg by pain score, acetaminophen 1 g scheduled, enoxaparin daily, PT twice daily, spirometer 10 an hour; discharge planned day 3 at 150 feet with pain controlled. Spirometer use 3 to 4 an hour; SpO2 94% awake, 92% asleep; bases diminished, no crackles. Temperature 37.4 this morning. Dressing unchanged; calf soft.
Assessment: pain is above goal with activity despite the ordered medication, the opioid is causing nausea that is limiting intake and therapy, and mobility is well short of the discharge criterion.
Recommendation: please review the pain and antiemetic orders. I have started ondansetron before doses per the order set, timed the acetaminophen and oxycodone before therapy, and added ice before sessions. Please advise on discharge timing with PT, given 60 feet today. I will call if vomiting passes two episodes, SpO2 falls below 90%, the temperature passes 38.3, or the dressing changes.

The grade

Graded 2026-10-01 03:54 UTC against the rubric above, by the same model.

Overall: passes. The plan reads like a unit nurse's: changes tied to responses, limits respected, the surgeon given a clean call. The attempt did not propose a specific alternative analgesic, which keeps it in scope.

How the examples are made and graded: the method. Every task of this job, with its length and when it comes within reach: Registered Nurses.