HESI Case Studies- Peripheral Vascular Disease (PVD) with Amputation
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.
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.
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.
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?
What action will the nurse implement to address Hans’ right leg pain?
Medicate Hans with the prescribed opioid analgesic immediately.
How should the nurse respond to the student?
Phantom limb pain is caused by the severing of peripheral nerves.
Which action will the nurse implement first?
Assess the client’s blood pressure and pulse.
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?
Place a large tourniquet proximal to the residual limb dressing.
Which intervention(s) should the nurse implement when administering the first unit of blood? (Select all that apply.)
Check Han’s arm identification and blood bands with another licensed nurse.
Infuse the unit of blood using an intravenous control pump.
The nurse enters the room and notes that Hans’ right leg is elevated on 2 pillows. Which action will the nurse implement?
Explain that the right leg should not be elevated on pillows.
The UAP looks confused and says, “Did you say put him on his stomach?” What is the best response by the nurse?
Putting him on his stomach will help prevent hip flexion contractures.
What nursing task can the nurse delegate to the UAP to help with the new admission?
Ask the UAP to orient the client to the room and to provide instructions on how the bed works.
Which goal should the nurse identify related to this nursing diagnosis?
The client will exhibit increased blood supply to the extremity.
Which nursing intervention should be included in the plan of care for this diagnosis?
Counsel on ways to prevent emotional upsets.
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.
Hans asked the rehabilitation nurse, “Why are you so worried about the shape of my stump?” How should the nurse respond?
We need to make sure the stump is cone shaped to ensure a good prosthetic fit.
Which statement by Hans indicates that he has accepted the amputation?
I decided to call my right leg, “Stumpy” and my prosthesis, “The Tree”.”
Which intervention should the nurse implement to help Hans deal with his grief?
Refer Hans to a professional counselor as soon as possible.
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
Hans is scared that he will be forced to go to the nursing home. How should the nurse respond?
Would you like me to call the social worker so the three of us can discuss other options?
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?
You can visit the apartment and talk to the staff before you decide if this is right for you.
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.
Hans tells the nurse that he will use his crutches when walking with his prosthesis. How should the nurse respond?
Does the use of your crutches make you feel safer when you are walking?
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?
Obtain a culture of the incisional drainage.
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?
I didn’t feel anything when I cut my foot, and it doesn’t hurt at all.
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?
The nurse teaches Hans about measures to prevent complications from PVD. Which statement by Hans indicates that the teaching has been effective?
I will not use any type of heating pad on my leg.
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.
What action will the home healthcare nurse implement first?
Call Hans to obtain permission to visit and arrange a time.
Hans asks the nurse, “What exactly will you be able to do for me?” How should the nurse respond?
I hope to help you stay out of the hospital and to prevent further complications.