HESI Case Studies–Medical/Surgical-PVD with Amputation (Hans)

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