Nokea
Nurses' Notes
Vital Signs
Diagnostic Results
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 the right leg upon falling. Right leg was immobilized at the scene and the 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.
The nurse is assisting in the plan of care for the client who has compartment syndrome. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.
- A. Open the splint
- B. Place the client on NPO status
- C. Place the client's right leg in a dependent position
- D. Obtain a urinalysis
Correct Answer: A (anticipated), B (anticipated), C (contraindicated), D (anticipated)
Rationale: Opening the splint relieves pressure in compartment syndrome; NPO status prepares for surgery; a dependent position worsens swelling; urinalysis assesses for rhabdomyolysis.
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Nurses' Notes
Vital Signs
Laboratory Results
Day 1, 1000:
The client reports mid abdominal pain. Client reports pain as 7 on a scale of 0 to 10. The client states, "I haven't had a bowel movement in 4 days." The client states, "I also have vomited once or twice."
Physical Exam:
General: uncomfortable, grimacing
HEENT: dry mucous membranes
Cardiovascular: S1, S2, no murmur
Respiratory: bilateral breath sounds clear
Gastrointestinal: tenderness to palpation, high-pitched bowel sounds
Skin: no jaundice noted
Social history: drinks 1 to 2 glasses of wine daily. Client reports no tobacco use.
The nurse is assisting with the care of a client. For each finding, click to specify if the finding is consistent with small bowel obstruction or acute pancreatitis. Each finding may support more than 1 disease process.
- A. Pain level
- B. Social history
- C. Skin findings
- D. Lipase level
- E. WBC count
- F. Abdominal findings
Correct Answer: A (small bowel obstruction, acute pancreatitis), B (acute pancreatitis), C (neither), D (acute pancreatitis), E (small bowel obstruction, acute pancreatitis), F (small bowel obstruction)
Rationale: Pain level and abdominal findings (tenderness, high-pitched bowel sounds) support small bowel obstruction and acute pancreatitis; social history (alcohol use) and lipase support pancreatitis; WBC count supports both; skin findings (no jaundice) support neither.
A nurse is assisting in the care of the client who is postoperative following a fasciotomy.
Nurses' Notes
Vital Signs
Diagnostic Results
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.
Day 3, 2300:
Client is alert and oriented to person, place, and time. Bilateral breath sounds clear and present throughout. Right leg with splint in place. Incisional dressing dry and intact. Wound drain to negative-pressure vacuum, draining small amounts of serosanguinous fluid. Bilateral pedal pulses 3+. feet warm with intact movement and sensation. Client reports pain as a 4 on a scale of 0 to 10.
The nurse is reviewing the client's electronic medical record (EMR). Select statements in the EMR that indicate the client's condition is improving since implementing interventions.
- A. Temperature 37.8°C (100°F)
- B. Client is alert and oriented to person, place, and time
- C. Bilateral breath sounds clear and present throughout
- D. Feet warm with intact movement and sensation
- E. Heart rate 98/min
- F. Bilateral pedal pulses 3+
- G. Respiratory rate 20/min
Correct Answer: B,C,D
Rationale: Alertness, clear breath sounds, and warm feet with intact sensation indicate recovery from the initial injury and fasciotomy.
A nurse is assisting in the care of a client who is in the emergency department (ED) following a ski accident.
Nurses' Notes
Vital Signs
Diagnostic Results
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 the right leg upon falling. Right leg was immobilized at the scene and the 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.
The nurse is collecting data on the client. Which of the following findings require follow up?
- A. Findings of right lower extremity assessment
- B. Pain level
- C. Level of consciousness
- D. Oxygen saturation
- E. Right pedal pulses
- F. Temperature
- G. X-ray results
Correct Answer: A,B,E
Rationale: Right lower extremity findings (swelling, open wound), severe pain, and weak right pedal pulses indicate potential fracture or vascular compromise needing follow-up.
A nurse is reinforcing teaching with a client who has herpes simplex virus type 2. Which of the following statements by the client indicates an understanding of the teaching?
- A. I am only contagious while the lesions are present.
- B. The virus cannot spread to areas other than the genital area.
- C. I can have unprotected sex as long as I am taking acyclovir.
- D. The lesions may reoccur in times of stress.
Correct Answer: D
Rationale: Herpes simplex virus type 2 can recur during stress due to immune suppression, indicating client understanding.
A nurse is assisting with the plan of care for a client who has aspiration pneumonia and hypoxia. Which of the following actions should the nurse plan to take?
- A. Initiate fall precautions.
- B. Apply petroleum jelly to the client's nares.
- C. Implement contact precautions.
- D. Maintain the client in a supine position.
Correct Answer: A
Rationale: Hypoxia increases fall risk due to weakness or confusion, making fall precautions essential in aspiration pneumonia care.