Difficulty: Medium
Average Score: 84%
Simulated
Passage / Scenario
Nurse's NotesHistory and Physical
Orders
Vital Signs
Laboratory Results
Day 2, 0730:
Tolerated the surgical procedure well and has been stable since surgery.
Day 3, 0700:
Client is postoperative below-the-knee amputation of the right leg, sitting up with the right residual limb hanging off the bed. Morphine on demand in the left hand area; there is no redness or drainage at the site, with 50 mL per hour infusing. Assessment.
Exhibits
Data is evaluated to determine possible condition and appropriate interventions. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the clientÔÇÖs progress.
Data is evaluated to determine possible condition and appropriate interventions. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
Correct answer
C
Rationale
Condition: Postoperative infection (C). Actions: Administer antibiotics (C), culture wound drainage (A). Parameters: Temperature (B), white blood cell count (C). Rationale: Elevated WBC and temperature suggest infection, requiring antibiotics and monitoring.