Difficulty: Medium
Average Score: 63%
Simulated
Passage / Scenario
Medication Administration RecordÔÇó 1700: Dextrose 5% in 0.45% sodium chloride (D5/0.45% NaCl) at 100 mL/hr
ÔÇó 1700: Promethazine 25 mg IV bolus every 4 hours PRN for nausea/vomiting
ÔÇó 1715: Morphine 4 mg IV bolus every 6 hours PRN for pain
ÔÇó 2115: Acetaminophen 625 mg PO every 6 hours PRN if temperature > 38.6┬░C (101.5┬░F)
ÔÇó Discontinue Morphine (Note: The morphine has not yet been administered as the order is due in the future.)
Nurses' Notes
The client was received from the Post Anesthesia Care Unit (PACU) with initial vital signs recorded. The client is drowsy but arouses to verbal stimuli and is oriented to person, place, and time. The client is able to move all extremities and follow simple commands.
The heart rhythm is normal sinus, bilateral radial and pedal pulses are +2, and capillary refill is less than 2 seconds. Respiratory rate is 18/min with clear lung sounds and oxygen saturation of 96% on 2 L via nasal cannula. Bowel sounds are hypoactive in all four quadrants. The indwelling urinary catheter is draining clear yellow urine. The dressing on the right knee is dry and intact, with no drainage noted.
At 1830, the client was repositioned for comfort with side rails up x2 and the call light within reach. The client remains somewhat lethargic but arouses easily and reports nausea and pain, rating the pain as 6 on a scale from 0 to 10. Metoclopramide 10 mg IV was administered at 1830 for nausea. The client is positioned comfortably with the side rails up and call light within reach.
Physical Examination
ÔÇó Heart Rate: 88/min
ÔÇó Respiratory Rate: 18/min
ÔÇó Blood Pressure: 115/55 mm Hg
ÔÇó Temperature: 36.4┬░C (97.5┬░F)
ÔÇó Oxygen Saturation: 96% on 2 L via nasal cannula
ÔÇó General Behavior: Drowsy but arouses easily, somewhat lethargic
ÔÇó Pain Level: Rated as 6 on a scale from 0 to 10
ÔÇó Bowel Sounds: Hypoactive in all four quadrants
ÔÇó Urinary Output: Clear yellow urine from indwelling catheter
ÔÇó Knee Dressing: Dry and intact with no drainage
A nurse is caring for a client who is 6 hours postoperative following a right knee arthroplasty. The client has been receiving medications and fluids as outlined below.Exhibits Complete the following sentence by selecting the most appropriate action from the choices below: The nurse should first:---------------------,followed by--------------------------------------
Correct answer
A,B
Rationale
Action to Take: A, B; Potential Condition: Postoperative pain; Parameter to Monitor: Pain level, Client comfort.
Rationale: After a knee arthroplasty, pain management is crucial for the client's comfort and recovery. Administering additional morphine (A) addresses postoperative pain. Repositioning the client (B) is important to prevent complications such as pressure ulcers. Assessing the area for the restraint (C) and padding the client's wrists (D) are not immediate priorities. Ensuring the call light is within reach (E) is important but not the first action to take.
Rationale: After a knee arthroplasty, pain management is crucial for the client's comfort and recovery. Administering additional morphine (A) addresses postoperative pain. Repositioning the client (B) is important to prevent complications such as pressure ulcers. Assessing the area for the restraint (C) and padding the client's wrists (D) are not immediate priorities. Ensuring the call light is within reach (E) is important but not the first action to take.