PN Adult Medical Surgical 2023

Extract:

Nurses' Notes
Day 1:
Client brought to the emergency department (ED) following a fall that occurred while downhill skiing. Client states they fell when turning to avoid hitting another skier. Client reports feeling a severe, sudden pain of right leg upon falling. Right leg was immobilized at the scene and client transported to the ED.
Client states they were wearing a helmet while skiing. Client reports no headache or loss of consciousness.
Client reports pain as 10 on a scale of 0 to 10 to the right lower leg Just below the knee and is unable to bear weight.
Right proximal tibia ecchymotic and swollen below the knee. Area is painful to touch. Open area noted on skin with bone visible. Right knee appears displaced. Left pedal pulses 3+, foot warm with intact movement and sensation. Right pedal pulses 1+, foot cool to palpation with minimal movement and reduced sensation.
Diagnostic Results
Day 1:
X-ray of right leg: open spiral tibial shaft fracture

Question 1 of 5

For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client. Prescription: Open the splint

Potential Prescription	Anticipated	Contraindicated
Open the splint
Obtain a urinalysis
Place the client on NPO status
Place the client's right leg in a dependent position

Correct Answer:

Rationale: Opening the splint relieves pressure in compartment syndrome.

Question 2 of 5

Which of the following actions should the nurse take? (Post-fasciotomy)

A. Prepare to administer an antibiotic B. Administer an analgesic C. Restrict fluid intake. D. Prepare to obtain a wound culture. E. Initiate supplemental oxygen. F. Elevate the leg. G. Monitor dressing.

Correct Answer: A,B,D

Rationale: Antibiotics prevent infection, analgesics manage pain, and a wound culture assesses for infection post-fasciotomy.

Extract:

Question 3 of 5

A nurse is assisting with the plan of care for a client who has osteoarthritis. The client reports knee stiffness upon ambulation. Which of the following interventions should the nurse include in the plan of care?

A. Apply moist heat prior to ambulation. B. Delay ambulation until the next day C. Use a continuous passive motion machine D. Rest in a soft chair E. Apply cold packs. F. Increase weight-bearing exercise. G. Avoid all movement.

Correct Answer: A

Rationale: Moist heat reduces stiffness and improves mobility in osteoarthritis.

Question 4 of 5

A nurse is caring for a client who has returned to the unit following a cardiac catheterization using a femoral approach. Which of the following methods should the nurse use to monitor for complications?

A. Palpate the client's brachial pulses and compare bilaterally. B. Check for jugular vein distention while the client is supine. C. Check the client's blood pressure while the client lies supine, sits, and stands. D. Palpate the client's pedal pulses and compare bilaterally. E. Monitor respiratory rate. F. Check for chest pain. G. Assess skin temperature.

Correct Answer: D

Rationale: Pedal pulses assess for femoral artery complications like hematoma or occlusion.

Question 5 of 5

A nurse is collecting data from an older adult client who has cystitis. Which of the following findings should the nurse anticipate?

A. Confusion B. Hypothermia C. Referred pain in the right shoulder D. Orange colored urine E. Fever F. Dysuria G. Urgency

Correct Answer: A

Rationale: Confusion is common in older adults with cystitis due to altered mental status from infection.

PN Adult Medical Surgical 2023 | Nurselytic

Nurselytic

ATI LPN

ATI LPN