HESI Case Studies–Medical/Surgical-PVD with Amputation (Hans) – Flashcards
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1. Which action will the nurse implement first since informed consent cannot be obtained?
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Prepare Hans for surgery and document that no family member is available
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2. What must the nurse do with Hans' personal items?
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Assign two nurses to place the items in a bag and place them in the hospital safe
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3. What is the purpose of the "time out?"
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So all members of the OR team participate in the positive identification of the client, identify the correct site, and identify the planned procedure
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4. What will the operating room nurse do with the amputated limb?
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Ensure that the limb is sent to the incinerator so that it can be burned
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5. 125mL/hr IV is ordered. The nurse hangs a new bag of IV fluids and check the rate. The IV tubing delivers 15 drops/mL. How many drops/min will the IV set deliver?
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31
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6. What action will the nurse implement to address Hans' right leg pain?
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Medicate Hans with the prescribed opioid analgesic immediately
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7. How should the nurse respond to the student?
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Phantom limb pain is caused by the severing of peripheral nerves
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8. Which action will the nurse implement first?
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Assess the client's blood pressure and pulse
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9. Which action will the nurse implement first?
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Place a large tourniquet proximal to the residual limb dressing
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10. Which intervention(s) should the nurse implement when administering the first unit of blood? (Select all)
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-Check Hans' arm identification and blood bands with another licensed nurse -Infuse the unit of blood using an intravenous control pump
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11. Which action will the nurse implement?
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Explain the the right leg should not be elevated on pillows
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12. What is the best response by the nurse?
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"Putting him on his stomach will help me prevent hip flexion contractures."
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13. What nursing task can the nurse delegate to the UAP to help with the new admission?
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Ask the UAP to orient the new client to the room and to provide instructions on how the bed works
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14. Which goal should the nurse identify related to this nursing diagnosis?
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The client will exhibit increased blood supply to the extremity
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15. Which nursing intervention should be included in the plan of care for this diagnosis
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Counsel on ways to prevent emotional upsets
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16. What action by Hans will help toughen the residual limb at this time in his recovery?
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Push the residual limb against a hard surface every 2 hours
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17. How should the nurse respond?
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"We need to make sure the stump is cone shaped to ensure a good prosthetic fit."
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18. Which statement by Hans indicates that he has accepted the amputation?
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"I decided to call my right leg, 'Stumpy' and my prosthesis, 'The Tree'."
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19. Which intervention should the nurse implement to help Hans deal with his grief?
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Refer Hans to a professional counselor as soon as possible
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20. Which healthcare issue is most prevalent in caring for the homeless population?
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The large number of homeless who are mentally ill and/or substance abusers
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21. How should the nurse respond?
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"Would you like me to call the social worker so the three of us can discuss other options?"
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22. How should the nurse respond to Hans' question?
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"You can visit the apartment and talk to the staff before you decide if this is right for you."
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23. Which statement by Hans indicates that successful learning has occurred?
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"If I get a cut or wound on my left foot I will come to the Veteran's clinic."
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24. How should the nurse respond?
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"Does the use of your crutches make you feel safer when you are walking?"
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25. Which action should the nurse implement first?
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Obtain a culture of the incisional drainage
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26. Which statement by Hans reflects his PVD?
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"I didn't feel anything when I cut my foot, and it doesn't hurt at all."
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27. How should the nurse correctly document this data?
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Intermittent claudication
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28. Which statement by Hans indicates that the teaching has been effective?
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"I will not use any type of heating pad on my leg."
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29. In teaching Hans about his prescription for antibiotics, which instruction should the nurse include?
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Notify the clinic if you develop any white patches in your mouth or diarrhea
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30. What action will the home healthcare nurse implement first?
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Call Hans to obtain permission to visit and arrange a time
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31. How should the nurse respond?
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"I hope to help you stay out of the hospital and to prevent further complications."
