HESI Case Studies- Peripheral Vascular Disease (PVD) with Amputation – 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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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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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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The nurse hangs a new bag of IV fluids and checks 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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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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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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Which action will the nurse implement first?
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Assess the client's blood pressure and pulse.
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Hans' blood pressure is 84/58, his pulse is 114, and the residual limb dressing is soaked in blood. He is difficult to arouse. 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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Which intervention(s) should the nurse implement when administering the first unit of blood? (Select all that apply.)
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Check Han's arm identification and blood bands with another licensed nurse. Infuse the unit of blood using an intravenous control pump.
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The nurse enters the room and notes that Hans' right leg is elevated on 2 pillows. Which action will the nurse implement?
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Explain that the right leg should not be elevated on pillows.
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The UAP looks confused and says, "Did you say put him on his stomach?" What is the best response by the nurse?
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Putting him on his stomach will help prevent hip flexion contractures.
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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 client to the room and to provide instructions on how the bed works.
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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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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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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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Hans asked the rehabilitation nurse, "Why are you so worried about the shape of my stump?" 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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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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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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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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Hans is scared that he will be forced to go to the nursing home. 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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Hans later asks the nurse what assisted living is like and whether the nurse believes that this is a good choice for him. 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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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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Hans tells the nurse that he will use his crutches when walking with his prosthesis. 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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Hans tells the nurse that this is the first time he put on "The Tree" because his leg has been hurting. Which action should the nurse implement first?
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Obtain a culture of the incisional drainage.
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The nurse assesses Han's left leg and notices that he has a rather large cut on the bottom of his left foot. 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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Hans tells the nurse that every time he walks a short distance, he gets an aching or cramping type pain in his left leg. How should the nurse correctly document this data?
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Intermittent claudication
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The nurse teaches Hans about measures to prevent complications from PVD. 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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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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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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Hans asks the nurse, "What exactly will you be able to do for me?" How should the nurse respond?
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I hope to help you stay out of the hospital and to prevent further complications.
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