Video Library
RN Hesi Compass Exit proctored exam
Total Questions : 125
Showing 10 questions, Sign in for moreThe nurse is caring for a client who reports sudden right-sided numbness and weakness of the arm and leg. The nurse also observes a distinct right-sided facial droop. After reporting the findings to the healthcare provider, the nurse receives several prescriptions for the client, including a STAT computed tomography (CT) scan of the head. After obtaining vital signs, the nurse should implement which intervention?
The school nurse is preparing a presentation for elementary school teachers to inform them when a child should be referred to the school clinic for further follow-up. The teachers should be instructed to report which situations to the school nurse? Select all that apply.
The nurse is planning care for a client who has a fourth degree midline laceration that occurred during vaginal delivery of an 8- pound 10-ounce (3674 grams) infant. Which intervention has the highest priority for this client?
Client is a 48-year-old male with gangrene of the right lower leg which has not been responsive to treatment. A below-the- knee amputation (BKA) of the right lower leg has been performed. Has a history of peripheral vascular disease (PVD) and hypertension (HTN) and has a pacemaker for 2nd degree Type II atrioventricular (AV) heart block.
Postoperative Day (POD) 2
0845
Client tolerated the surgical procedure well and has been stable since surgery.
POD 3
0700
Is postoperative below-the-knee amputation right leg day 3. He is sitting up with his left leg and right leg residual limb hanging off the bed. There is patient-controlled analgesia (PCA) of morphine on demand in the left hand area; there is no redness at the site with 0.9% sodium chloride infusing at 50 mL/hr.
Assessment
General: Alert, oriented to person, place, time, and situation.
Eyes: Pupils equal, round, reactive to light accommodation (PERRLA).
Lungs: Lungs clear all lobes.
Heart: Telemetry monitor displaying normal sinus rhythm (NSR).
Abdomen: Abdomen soft, bowel sounds in all 4 quadrants. Denies pain with urination and describes urine as light yellow.
Right leg: Right leg incision is open to air, skin to the area is cool to touch, and edema noted along the incision. Sutures intact, no redness noted, popliteal pulses strong bilaterally and wound drain with approximately 100 mL red drainage present right leg. Reports pain is a 2 on a 0 to 10 scale, right residual limb area.
Left leg: 2+ pedal pulse, loss of hair on the lower leg, skin is dry, scaly, cool to touch, thickened toenails noted, and capillary refill is greater than 4 seconds.
Postoperative Day (POD) 3
0700
Temperature: 98.2° F (36.7° C) orally
Heart rate: 88 beats/minute normal sinus rhythm (NSR)
Respirations: 20 breaths/minute
Blood pressure: 126/84 mm Hg
Oxygen saturation: 95% on room air
Pain: 2 on a 0 to 10 scale, right leg incisional area
Admit
0845
Leave incision open to air
Clean residual limb twice daily with 4 by 4's moistened with 0.9% sodium chloride and pat dry
Right residual limb to lie flat in bed
Prone position 2 times daily for 30 minutes
Atenolol 50 mg PO twice daily
Lovastatin 20 mg PO with evening meal
Enoxaparin 40 mg subcutaneous every morning
Penicillin 500 mg IV piggyback (IVPB) every 6 hours
Incentive spirometer
Out of bed with assistance by physical therapy (PT) twice daily
Laboratory: complete blood count (CBC) with differential, basic metabolic panel, partial prothrombin time (PTT)
Low sodium diet
Infuse 0.9% sodium chloride IV at 50 mL hour
Patient-controlled analgesia (PCA) settings
Drug: Morphine sulfate
Solution: 0.9% Sodium chloride
Concentration: 1 mg/mL
Bolus dose: 1 mg
Lockout: 8 minutes
Morphine 1 mg IV push (IVP) every 2 hours PRN for breakthrough pain
The nurse is reviewing the client’s postoperative assessment findings. Which findings require immediate follow-up? (Select all that apply)
Client is a 48-year-old male with gangrene of the right lower leg which has not been responsive to treatment. A below-the-knee amputation (BKA) of the right lower leg has been performed. Has a history of peripheral vascular disease (PVD) and hypertension (HTN) and has a pacemaker for 2nd degree Type II atrioventricular (AV) heart block.
Postoperative Day (POD) 2
0845
Client tolerated the surgical procedure well and has been stable since surgery.
POD 3
0700
Is postoperative below-the-knee amputation right leg day 3. He is sitting up with his left leg and right leg residual limb hanging off the bed. There is patient-controlled analgesia (PCA) of morphine on demand in the left hand area; there is no redness at the site with 0.9% sodium chloride infusing at 50 mL/hr.
Assessment
General: Alert, oriented to person, place, time, and situation.
Eyes: Pupils equal, round, reactive to light accommodation (PERRLA).
Lungs: Lungs clear all lobes.
Heart: Telemetry monitor displaying normal sinus rhythm (NSR).
Abdomen: Abdomen soft, bowel sounds in all 4 quadrants. Denies pain with urination and describes urine as light yellow.
Right leg: Right leg incision is open to air, skin to the area is cool to touch, and edema noted along the incision. Sutures intact, no redness noted, popliteal pulses strong bilaterally and wound drain with approximately 100 mL red drainage present right leg. Reports pain is a 2 on a 0 to 10 scale, right residual limb area.
Left leg: 2+ pedal pulse, loss of hair on the lower leg, skin is dry, scaly, cool to touch, thickened toenails noted, and capillary refill is greater than 4 seconds.
Postoperative Day (POD) 3
0700
Temperature: 98.2° F (36.7° C) orally
Heart rate: 88 beats/minute normal sinus rhythm (NSR)
Respirations: 20 breaths/minute
Blood pressure: 126/84 mm Hg
Oxygen saturation: 95% on room air
Pain: 2 on a 0 to 10 scale, right leg incisional area
Admit
0845
Leave incision open to air
Clean residual limb twice daily with 4 by 4's moistened with 0.9% sodium chloride and pat dry
Right residual limb to lie flat in bed
Prone position 2 times daily for 30 minutes
Atenolol 50 mg PO twice daily
Lovastatin 20 mg PO with evening meal
Enoxaparin 40 mg subcutaneous every morning
Penicillin 500 mg IV piggyback (IVPB) every 6 hours
Incentive spirometer
Out of bed with assistance by physical therapy (PT) twice daily
Laboratory: complete blood count (CBC) with differential, basic metabolic panel, partial prothrombin time (PTT)
Low sodium diet
Infuse 0.9% sodium chloride IV at 50 mL hour
Patient-controlled analgesia (PCA) settings
Drug: Morphine sulfate
Solution: 0.9% Sodium chloride
Concentration: 1 mg/mL
Bolus dose: 1 mg
Lockout: 8 minutes
Morphine 1 mg IV push (IVP) every 2 hours PRN for breakthrough pain
Select the 3 assessment findings that indicate ineffective peripheral tissue perfusion for this client.
Client is a 48-year-old male with gangrene of the right lower leg which has not been responsive to treatment. A below-the-knee amputation (BKA) of the right lower leg has been performed. Has a history of peripheral vascular disease (PVD) and hypertension (HTN) and has a pacemaker for 2nd degree Type II atrioventricular (AV) heart block.
Postoperative Day (POD) 2
0845
Client tolerated the surgical procedure well and has been stable since surgery.
POD 3
0700
Is postoperative below-the-knee amputation right leg day 3. He is sitting up with his left leg and right leg residual limb hanging off the bed. There is patient-controlled analgesia (PCA) of morphine on demand in the left hand area; there is no redness at the site with 0.9% sodium chloride infusing at 50 mL/hr.
General: Alert, oriented to person, place, time, and situation.
Eyes: Pupils equal, round, reactive to light accommodation (PERRLA).
Lungs: Lungs clear all lobes.
Heart: Telemetry monitor displaying normal sinus rhythm (NSR).
Abdomen: Abdomen soft, bowel sounds in all 4 quadrants. Denies pain with urination and describes urine as light yellow.
Right leg: Right leg incision is open to air, skin to the area is cool to touch, and edema noted along the incision. Sutures intact, no redness noted, popliteal pulses strong bilaterally and wound drain with approximately 100 mL red drainage present right leg. Reports pain is a 2 on a 0 to 10 scale, right residual limb area.
Left leg: 2+ pedal pulse, loss of hair on the lower leg, skin is dry, scaly, cool to touch, thickened toenails noted, and capillary refill is greater than 4 seconds.
Postoperative Day (POD) 3
0700
Temperature: 98.2° F (36.7° C) orally
Heart rate: 88 beats/minute normal sinus rhythm (NSR)
Respirations: 20 breaths/minute
Blood pressure: 126/84 mm Hg
Oxygen saturation: 95% on room air
Pain: 2 on a 0 to 10 scale, right leg incisional area
0835
|
Intake |
Output |
|
325 mL oral |
100 mL wound drain |
|
50 mL IV fluids |
|
Day 3
1000
|
Laboratory Test |
Result |
Reference Range |
|
White blood cells |
10,000/mm3 (10.6 x 109/L) |
5,000 to 10,000/mm3 (5 to 10 x 109 /L) |
|
Hemoglobin |
16.2 g/dL (162 g/L) |
14 to 18 g/dL (140 to 180 g/L) |
|
Hematocrit |
49% (0.49 volume fraction) |
42 to 52% (0.42 to 0.52 volume fraction) |
|
Platelets |
349,000/mm3 (349 x 109/L) |
150,000 to 400,000/mm3 (150 to 400 x 109 /L) |
|
Mean corpuscular volume |
92 fL |
80 to 100 fL |
|
Mean corpuscular hemoglobin |
28 pg |
27 to 31 pg |
|
Mean corpuscular hemoglobin concentration |
35% (35 g/L) |
32 to 36% (32 to 36 g/L) |
|
Partial thromboplastin time |
52 seconds |
60 to 70 seconds |
White Blood Cell Differential
|
Laboratory Test |
Result |
Reference Range |
|
Neutrophils |
62% |
55 to 70% |
|
Lymphocytes |
45% |
20 to 40% |
|
Monocytes |
8% |
2 to 8% |
|
Eosinophils |
3% |
1 to 4% |
|
Basophils |
1% |
0.5 to 1% |
Complete Metabolic Panel
|
Laboratory Test |
Result |
Reference Range |
|
Sodium |
141 mEq/L (141 mmol/L) |
136 to 145 mEq/L (135 to 148 mmol/L) |
|
Potassium |
4 mEq/L (4 mmol/L) |
3.5 to 5 mEq/L (3.5 to 5 mmol/L) |
|
Chloride |
100 mg/dL (100 mmol/L) |
98 to 106 mg/dL (98 to 106 mmol/L) |
|
Blood urea nitrogen |
16 mg/dL (5.71 mmol/L) |
7 to 18 mg/dL (3.6 to 7.1 mmol/L) |
|
Creatinine |
0.8 mg/dL (70.72 μmol/L) |
0.6 to 1.2 mg/dL (53.04 to 106.08 μmol/L) |
|
Carbon dioxide |
33 mEq/L (33 mmol/L) |
22 to 30 mEq/L (22 to 30 mmol/L) |
Admit
0845
Leave incision open to air
Clean residual limb twice daily with 4 by 4's moistened with 0.9% sodium chloride and pat dry
Right residual limb to lie flat in bed
Prone position 2 times daily for 30 minutes
Atenolol 50 mg PO twice daily
Lovastatin 20 mg PO with evening meal
Enoxaparin 40 mg subcutaneous every morning
Penicillin 500 mg IV piggyback (IVPB) every 6 hours
Incentive spirometer
Out of bed with assistance by physical therapy (PT) twice daily
Laboratory: complete blood count (CBC) with differential, basic metabolic panel, partial prothrombin time (PTT)
Low sodium diet
Infuse 0.9% sodium chloride IV at 50 mL hour
Patient-controlled analgesia (PCA) settings
Drug: Morphine sulfate
Solution: 0.9% Sodium chloride
Concentration: 1 mg/mL
Bolus dose: 1 mg
Lockout: 8 minutes
Morphine 1 mg IV push (IVP) every 2 hours PRN for breakthrough pain
Drag the Word Choices to complete the sentence.
The client is at risk for , and .
Explanation
Identification of priority postoperative complications following a below-the-knee amputation (BKA) in a client with peripheral vascular disease is important. Postoperative patients are at risk for multiple complications related to immobility, surgical trauma, impaired circulation, and reduced lung expansion. In this case, the client is early in recovery and demonstrates behaviors and orders that directly influence risk for musculoskeletal, vascular, and respiratory complications. The nurse must recognize expected risks to guide preventive interventions.
Rationale for correct choices:
• Contractures: Contractures are a major risk after amputation due to prolonged immobility and improper positioning of the residual limb. In this case, the residual limb is noted to be hanging off the bed, and although orders include positioning interventions, the client is still early in recovery. Flexion positioning and lack of proper limb extension can lead to muscle shortening, particularly in the hip and knee. Prone positioning orders are specifically intended to prevent flexion contractures.
• Deep vein thrombosis: The client is at high risk for deep vein thrombosis due to recent surgery, immobility, and underlying peripheral vascular disease. Surgical trauma increases coagulation activity, while decreased mobility reduces venous return from the lower extremities. Although the client is receiving enoxaparin, the risk remains significant in the early postoperative period. Prevention strategies such as early ambulation and anticoagulation are essential to reduce this complication.
• Atelectasis: Atelectasis is a common postoperative respiratory complication caused by shallow breathing, decreased lung expansion, and effects of anesthesia and opioid use. Although lung sounds are currently clear, the client is still in the early postoperative phase and receiving morphine via PCA, which can depress respiratory effort. Incentive spirometry is ordered to prevent alveolar collapse. Without adequate pulmonary hygiene, atelectasis may develop quickly.
Rationale for incorrect choices:
• Neuroma: A neuroma is a later complication that occurs due to abnormal nerve regeneration at the amputation site and typically develops weeks to months after surgery. It presents with localized nerve pain or phantom limb sensations rather than immediate postoperative risk. At this stage (POD 3), it is not a priority concern compared to immobility and respiratory complications. Prevention is not acute but long-term in nature.
• Infection: While infection is always a postoperative risk, there are currently no signs of infection such as redness, fever, purulent drainage, or elevated white blood cell count beyond the upper limit of normal. The wound is described as clean, with no redness noted and sutures intact. Prophylactic antibiotics are also ordered. Therefore, infection is a potential but not the most immediate risk compared to contractures, DVT, and atelectasis.
Client is a 48-year-old male with gangrene of the right lower leg which has not been responsive to treatment. A below-the-knee amputation (BKA) of the right lower leg has been performed. Has a history of peripheral vascular disease (PVD) and hypertension (HTN) and has a pacemaker for 2nd degree Type II atrioventricular (AV) heart block.
Postoperative Day (POD) 2
0845
Client tolerated the surgical procedure well and has been stable since surgery.
POD 3
0700
Is postoperative below-the-knee amputation right leg day 3. He is sitting up with his left leg and right leg residual limb hanging off the bed. There is patient-controlled analgesia (PCA) of morphine on demand in the left hand area; there is no redness at the site with 0.9% sodium chloride infusing at 50 mL/hr.
Assessment
General: Alert, oriented to person, place, time, and situation.
Eyes: Pupils equal, round, reactive to light accommodation (PERRLA).
Lungs: Lungs clear all lobes.
Heart: Telemetry monitor displaying normal sinus rhythm (NSR).
Abdomen: Abdomen soft, bowel sounds in all 4 quadrants. Denies pain with urination and describes urine as light yellow.
Right leg: Right leg incision is open to air, skin to the area is cool to touch, and edema noted along the incision. Sutures intact, no redness noted, popliteal pulses strong bilaterally and wound drain with approximately 100 mL red drainage present right leg. Reports pain is a 2 on a 0 to 10 scale, right residual limb area.
Left leg: 2+ pedal pulse, loss of hair on the lower leg, skin is dry, scaly, cool to touch, thickened toenails noted, and capillary refill is greater than 4 seconds.
Postoperative Day (POD) 3
0700
Temperature: 98.2° F (36.7° C) orally
Heart rate: 88 beats/minute normal sinus rhythm (NSR)
Respirations: 20 breaths/minute
Blood pressure: 126/84 mm Hg
Oxygen saturation: 95% on room air
Pain: 2 on a 0 to 10 scale, right leg incisional area
0835
|
Intake |
Output |
|
325 mL oral |
100 mL wound drain |
|
50 mL IV fluids |
|
Day 3
1000
|
Laboratory Test |
Result |
Reference Range |
|
White blood cells |
10,000/mm3 (10.6 x 109/L) |
5,000 to 10,000/mm3 (5 to 10 x 109 /L) |
|
Hemoglobin |
16.2 g/dL (162 g/L) |
14 to 18 g/dL (140 to 180 g/L) |
|
Hematocrit |
49% (0.49 volume fraction) |
42 to 52% (0.42 to 0.52 volume fraction) |
|
Platelets |
349,000/mm3 (349 x 109/L) |
150,000 to 400,000/mm3 (150 to 400 x 109 /L) |
|
Mean corpuscular volume |
92 fL |
80 to 100 fL |
|
Mean corpuscular hemoglobin |
28 pg |
27 to 31 pg |
|
Mean corpuscular hemoglobin concentration |
35% (35 g/L) |
32 to 36% (32 to 36 g/L) |
|
Partial thromboplastin time |
52 seconds |
60 to 70 seconds |
White Blood Cell Differential
|
Laboratory Test |
Result |
Reference Range |
|
Neutrophils |
62% |
55 to 70% |
|
Lymphocytes |
45% |
20 to 40% |
|
Monocytes |
8% |
2 to 8% |
|
Eosinophils |
3% |
1 to 4% |
|
Basophils |
1% |
0.5 to 1% |
Complete Metabolic Panel
|
Laboratory Test |
Result |
Reference Range |
|
Sodium |
141 mEq/L (141 mmol/L) |
136 to 145 mEq/L (135 to 148 mmol/L) |
|
Potassium |
4 mEq/L (4 mmol/L) |
3.5 to 5 mEq/L (3.5 to 5 mmol/L) |
|
Chloride |
100 mg/dL (100 mmol/L) |
98 to 106 mg/dL (98 to 106 mmol/L) |
|
Blood urea nitrogen |
16 mg/dL (5.71 mmol/L) |
7 to 18 mg/dL (3.6 to 7.1 mmol/L) |
|
Creatinine |
0.8 mg/dL (70.72 μmol/L) |
0.6 to 1.2 mg/dL (53.04 to 106.08 μmol/L) |
|
Carbon dioxide |
33 mEq/L (33 mmol/L) |
22 to 30 mEq/L (22 to 30 mmol/L) |
Admit
0845
Leave incision open to air
Clean residual limb twice daily with 4 by 4's moistened with 0.9% sodium chloride and pat dry
Right residual limb to lie flat in bed
Prone position 2 times daily for 30 minutes
Atenolol 50 mg PO twice daily
Lovastatin 20 mg PO with evening meal
Enoxaparin 40 mg subcutaneous every morning
Penicillin 500 mg IV piggyback (IVPB) every 6 hours
Incentive spirometer
Out of bed with assistance by physical therapy (PT) twice daily
Laboratory: complete blood count (CBC) with differential, basic metabolic panel, partial prothrombin time (PTT)
Low sodium diet
Infuse 0.9% sodium chloride IV at 50 mL hour
Patient-controlled analgesia (PCA) settings
Drug: Morphine sulfate
Solution: 0.9% Sodium chloride
Concentration: 1 mg/mL
Bolus dose: 1 mg
Lockout: 8 minutes
Morphine 1 mg IV push (IVP) every 2 hours PRN for breakthrough pain
For each action, click to indicate whether the actions are indicated or contraindicated for postoperative amputation. Each column must have at least one response option selected.
Explanation
|
Action |
Contraindicated |
Indicated |
|
Instructions on equipment |
✔ |
|
|
Conditioning exercises of residual limb |
✔ |
|
|
Obtaining soft mattress overlay |
✔ |
|
|
Collaborative care |
✔ |
|
|
Strengthening exercises |
✔ |
|
|
Assessment for grieving |
✔ |
Care priorities following a below-the-knee amputation (BKA) include preventing complications such as contractures, promoting mobility and independence, supporting emotional adjustment, and coordinating interdisciplinary care. The client is in the early postoperative phase, where positioning, rehabilitation, and psychosocial support are essential. The nurse must distinguish between interventions that promote healing and function versus those that may increase risk of complications such as contractures or impaired rehabilitation.
Rationale for correct choices:
• Instructions on equipment: Teaching the client about prosthetic use, assistive devices, and mobility aids is an essential part of postoperative rehabilitation. Early education promotes adaptation and prepares the client for eventual ambulation and independence. It also reduces anxiety and increases participation in recovery. Education should begin early, even before prosthetic fitting, to support long-term functional outcomes.
• Conditioning exercises of residual limb: Conditioning exercises help maintain muscle strength, prevent contractures, and prepare the residual limb for prosthetic use. These exercises improve circulation and reduce stiffness, which is essential after amputation. They also promote proper shaping of the limb for future prosthesis fitting. Early initiation is critical in preventing long-term mobility limitations.
• Obtaining soft mattress overlay: A soft mattress is not recommended after amputation because it increases the risk of contractures by promoting prolonged flexion positioning of the hip and knee. Firm support surfaces help maintain proper body alignment and prevent joint deformities. Soft surfaces also reduce mobility and make repositioning more difficult. Therefore, a firmer mattress is preferred to support proper positioning and rehabilitation.
• Collaborative care: Interdisciplinary collaboration with physical therapy, occupational therapy, and prosthetics specialists is essential for comprehensive rehabilitation. This ensures coordinated care focused on mobility, self-care, and prosthetic readiness. Collaborative care improves functional recovery and reduces complications. It also supports individualized rehabilitation planning based on patient needs.
• Strengthening exercises: Strengthening exercises for remaining limbs and core muscles are important to compensate for the loss of a lower extremity. These exercises enhance balance, mobility, and independence in activities of daily living. They also prepare the client for prosthetic use and reduce fall risk. Gradual strengthening supports long-term functional recovery.
• Assessment for grieving: Grieving is a normal psychological response following limb loss and should be routinely assessed. Clients may experience denial, anger, depression, or adjustment difficulties. Early identification allows timely psychosocial support and counseling interventions. Addressing grief improves coping and promotes adaptation to body image changes and functional loss.
Client is a 48-year-old male with gangrene of the right lower leg which has not been responsive to treatment. A below-the-knee amputation (BKA) of the right lower leg has been performed. Has a history of peripheral vascular disease (PVD) and hypertension (HTN) and has a pacemaker for 2nd degree Type II atrioventricular (AV) heart block.
Postoperative Day (POD) 2
0845
Client tolerated the surgical procedure well and has been stable since surgery.
POD 3
0700
Is postoperative below-the-knee amputation right leg day 3. He is sitting up with his left leg and right leg residual limb hanging off the bed. There is patient-controlled analgesia (PCA) of morphine on demand in the left hand area; there is no redness at the site with 0.9% sodium chloride infusing at 50 mL/hr.
Assessment
General: Alert, oriented to person, place, time, and situation.
Eyes: Pupils equal, round, reactive to light accommodation (PERRLA).
Lungs: Lungs clear all lobes.
Heart: Telemetry monitor displaying normal sinus rhythm (NSR).
Abdomen: Abdomen soft, bowel sounds in all 4 quadrants. Denies pain with urination and describes urine as light yellow.
Right leg: Right leg incision is open to air, skin to the area is cool to touch, and edema noted along the incision. Sutures intact, no redness noted, popliteal pulses strong bilaterally and wound drain with approximately 100 mL red drainage present right leg. Reports pain is a 2 on a 0 to 10 scale, right residual limb area.
Left leg: 2+ pedal pulse, loss of hair on the lower leg, skin is dry, scaly, cool to touch, thickened toenails noted, and capillary refill is greater than 4 seconds.
Postoperative Day (POD) 3
0700
Temperature: 98.2° F (36.7° C) orally
Heart rate: 88 beats/minute normal sinus rhythm (NSR)
Respirations: 20 breaths/minute
Blood pressure: 126/84 mm Hg
Oxygen saturation: 95% on room air
Pain: 2 on a 0 to 10 scale, right leg incisional area
0835
|
Intake |
Output |
|
325 mL oral |
100 mL wound drain |
|
50 mL IV fluids |
|
Day 3
1000
|
Laboratory Test |
Result |
Reference Range |
|
White blood cells |
10,000/mm3 (10.6 x 109/L) |
5,000 to 10,000/mm3 (5 to 10 x 109 /L) |
|
Hemoglobin |
16.2 g/dL (162 g/L) |
14 to 18 g/dL (140 to 180 g/L) |
|
Hematocrit |
49% (0.49 volume fraction) |
42 to 52% (0.42 to 0.52 volume fraction) |
|
Platelets |
349,000/mm3 (349 x 109/L) |
150,000 to 400,000/mm3 (150 to 400 x 109 /L) |
|
Mean corpuscular volume |
92 fL |
80 to 100 fL |
|
Mean corpuscular hemoglobin |
28 pg |
27 to 31 pg |
|
Mean corpuscular hemoglobin concentration |
35% (35 g/L) |
32 to 36% (32 to 36 g/L) |
|
Partial thromboplastin time |
52 seconds |
60 to 70 seconds |
White Blood Cell Differential
|
Laboratory Test |
Result |
Reference Range |
|
Neutrophils |
62% |
55 to 70% |
|
Lymphocytes |
45% |
20 to 40% |
|
Monocytes |
8% |
2 to 8% |
|
Eosinophils |
3% |
1 to 4% |
|
Basophils |
1% |
0.5 to 1% |
Complete Metabolic Panel
|
Laboratory Test |
Result |
Reference Range |
|
Sodium |
141 mEq/L (141 mmol/L) |
136 to 145 mEq/L (135 to 148 mmol/L) |
|
Potassium |
4 mEq/L (4 mmol/L) |
3.5 to 5 mEq/L (3.5 to 5 mmol/L) |
|
Chloride |
100 mg/dL (100 mmol/L) |
98 to 106 mg/dL (98 to 106 mmol/L) |
|
Blood urea nitrogen |
16 mg/dL (5.71 mmol/L) |
7 to 18 mg/dL (3.6 to 7.1 mmol/L) |
|
Creatinine |
0.8 mg/dL (70.72 μmol/L) |
0.6 to 1.2 mg/dL (53.04 to 106.08 μmol/L) |
|
Carbon dioxide |
33 mEq/L (33 mmol/L) |
22 to 30 mEq/L (22 to 30 mmol/L) |
Admit
0845
Leave incision open to air
Clean residual limb twice daily with 4 by 4's moistened with 0.9% sodium chloride and pat dry
Right residual limb to lie flat in bed
Prone position 2 times daily for 30 minutes
Atenolol 50 mg PO twice daily
Lovastatin 20 mg PO with evening meal
Enoxaparin 40 mg subcutaneous every morning
Penicillin 500 mg IV piggyback (IVPB) every 6 hours
Incentive spirometer
Out of bed with assistance by physical therapy (PT) twice daily
Laboratory: complete blood count (CBC) with differential, basic metabolic panel, partial prothrombin time (PTT)
Low sodium diet
Infuse 0.9% sodium chloride IV at 50 mL hour
Patient-controlled analgesia (PCA) settings
Drug: Morphine sulfate
Solution: 0.9% Sodium chloride
Concentration: 1 mg/mL
Bolus dose: 1 mg
Lockout: 8 minutes
Morphine 1 mg IV push (IVP) every 2 hours PRN for breakthrough pain
Which item(s) should the nurse teach the client? Select all that apply.
Client is a 48-year-old male with gangrene of the right lower leg which has not been responsive to treatment. A below-the-knee amputation (BKA) of the right lower leg has been performed. Has a history of peripheral vascular disease (PVD) and hypertension (HTN) and has a pacemaker for 2nd degree Type II atrioventricular (AV) heart block.
Postoperative Day (POD) 2
0845
Client tolerated the surgical procedure well and has been stable since surgery.
POD 3
0700
Is postoperative below-the-knee amputation right leg day 3. He is sitting up with his left leg and right leg residual limb hanging off the bed. There is patient-controlled analgesia (PCA) of morphine on demand in the left hand area; there is no redness at the site with 0.9% sodium chloride infusing at 50 mL/hr.
Assessment
General: Alert, oriented to person, place, time, and situation.
Eyes: Pupils equal, round, reactive to light accommodation (PERRLA).
Lungs: Lungs clear all lobes.
Heart: Telemetry monitor displaying normal sinus rhythm (NSR).
Abdomen: Abdomen soft, bowel sounds in all 4 quadrants. Denies pain with urination and describes urine as light yellow.
Right leg: Right leg incision is open to air, skin to the area is cool to touch, and edema noted along the incision. Sutures intact, no redness noted, popliteal pulses strong bilaterally and wound drain with approximately 100 mL red drainage present right leg. Reports pain is a 2 on a 0 to 10 scale, right residual limb area.
Left leg: 2+ pedal pulse, loss of hair on the lower leg, skin is dry, scaly, cool to touch, thickened toenails noted, and capillary refill is greater than 4 seconds.
Postoperative Day (POD) 3
0700
Temperature: 98.2° F (36.7° C) orally
Heart rate: 88 beats/minute normal sinus rhythm (NSR)
Respirations: 20 breaths/minute
Blood pressure: 126/84 mm Hg
Oxygen saturation: 95% on room air
Pain: 2 on a 0 to 10 scale, right leg incisional area
0835
|
Intake |
Output |
|
325 mL oral |
100 mL wound drain |
|
50 mL IV fluids |
|
Day 3
1000
|
Laboratory Test |
Result |
Reference Range |
|
White blood cells |
10,000/mm3 (10.6 x 109/L) |
5,000 to 10,000/mm3 (5 to 10 x 109 /L) |
|
Hemoglobin |
16.2 g/dL (162 g/L) |
14 to 18 g/dL (140 to 180 g/L) |
|
Hematocrit |
49% (0.49 volume fraction) |
42 to 52% (0.42 to 0.52 volume fraction) |
|
Platelets |
349,000/mm3 (349 x 109/L) |
150,000 to 400,000/mm3 (150 to 400 x 109 /L) |
|
Mean corpuscular volume |
92 fL |
80 to 100 fL |
|
Mean corpuscular hemoglobin |
28 pg |
27 to 31 pg |
|
Mean corpuscular hemoglobin concentration |
35% (35 g/L) |
32 to 36% (32 to 36 g/L) |
|
Partial thromboplastin time |
52 seconds |
60 to 70 seconds |
White Blood Cell Differential
|
Laboratory Test |
Result |
Reference Range |
|
Neutrophils |
62% |
55 to 70% |
|
Lymphocytes |
45% |
20 to 40% |
|
Monocytes |
8% |
2 to 8% |
|
Eosinophils |
3% |
1 to 4% |
|
Basophils |
1% |
0.5 to 1% |
Complete Metabolic Panel
|
Laboratory Test |
Result |
Reference Range |
|
Sodium |
141 mEq/L (141 mmol/L) |
136 to 145 mEq/L (135 to 148 mmol/L) |
|
Potassium |
4 mEq/L (4 mmol/L) |
3.5 to 5 mEq/L (3.5 to 5 mmol/L) |
|
Chloride |
100 mg/dL (100 mmol/L) |
98 to 106 mg/dL (98 to 106 mmol/L) |
|
Blood urea nitrogen |
16 mg/dL (5.71 mmol/L) |
7 to 18 mg/dL (3.6 to 7.1 mmol/L) |
|
Creatinine |
0.8 mg/dL (70.72 μmol/L) |
0.6 to 1.2 mg/dL (53.04 to 106.08 μmol/L) |
|
Carbon dioxide |
33 mEq/L (33 mmol/L) |
22 to 30 mEq/L (22 to 30 mmol/L) |
Admit
0845
Leave incision open to air
Clean residual limb twice daily with 4 by 4's moistened with 0.9% sodium chloride and pat dry
Right residual limb to lie flat in bed
Prone position 2 times daily for 30 minutes
Atenolol 50 mg PO twice daily
Lovastatin 20 mg PO with evening meal
Enoxaparin 40 mg subcutaneous every morning
Penicillin 500 mg IV piggyback (IVPB) every 6 hours
Incentive spirometer
Out of bed with assistance by physical therapy (PT) twice daily
Laboratory: complete blood count (CBC) with differential, basic metabolic panel, partial prothrombin time (PTT)
Low sodium diet
Infuse 0.9% sodium chloride IV at 50 mL hour
Patient-controlled analgesia (PCA) settings
Drug: Morphine sulfate
Solution: 0.9% Sodium chloride
Concentration: 1 mg/mL
Bolus dose: 1 mg
Lockout: 8 minutes
Morphine 1 mg IV push (IVP) every 2 hours PRN for breakthrough pain
For each client activity, click to indicate whether the activity shows positive or negative health promotion postoperative amputation due to extensive peripheral vascular disease (PVD). Each row must have one option response selected.
Explanation
This case focuses on identifying adaptive versus maladaptive behaviors in a postoperative below-the-knee amputation (BKA) client with peripheral vascular disease. Postoperative recovery requires a combination of physical rehabilitation, psychological adjustment, and active participation in self-care. Positive health behaviors include mobility, engagement in learning, and participation in care, while negative behaviors often reflect avoidance, dependence, or poor adjustment to body image changes. The nurse must evaluate which actions promote healing, independence, and long-term functional recovery.
Rationale:
• Executes pull ups on trapeze bar: Using a trapeze bar demonstrates active participation in mobility and strengthening of upper body muscles. This activity helps prevent complications of immobility such as pressure injuries, atelectasis, and deconditioning. It also promotes independence in repositioning and transfers, which is essential after lower limb amputation. Engaging in physical activity early supports functional recovery and prosthetic readiness.
• Avoids looking at residual limb: Avoidance of the residual limb indicates poor psychological adjustment and possible denial or body image disturbance. This behavior can delay emotional acceptance of the amputation and interfere with rehabilitation participation. It may also increase risk of depression or anxiety. Early exposure and gradual acceptance of the limb are important for successful adaptation.
• Asks questions about self care: Asking questions reflects engagement in learning and readiness to participate in postoperative care. This behavior indicates the client is processing information and preparing for self-management of the residual limb and overall health. It supports improved adherence to care plans and reduces anxiety through education. Active participation in self-care learning is a key indicator of positive adjustment.
• Turns side to side: Turning side to side helps prevent pressure injuries, improves circulation, and reduces the risk of respiratory complications. It also promotes proper positioning of the residual limb, which is essential for preventing contractures. This activity demonstrates cooperation with postoperative mobility recommendations. Regular repositioning is a fundamental component of recovery after amputation.
• Inquires about blood pressure: Asking about blood pressure indicates awareness and engagement in overall health monitoring, particularly important given the client’s history of hypertension and vascular disease. This behavior shows the client is interested in understanding their condition and participating in long-term management. It also supports secondary prevention of vascular complications. Health-related questioning reflects positive coping and learning readiness.
• Requests nurse to perform wound care: Consistently relying on the nurse for wound care reflects dependence and lack of engagement in self-care development. While assistance is appropriate early postoperatively, the long-term goal is gradual patient involvement in residual limb care. Refusal or avoidance of learning wound care skills delays independence. This behavior does not support optimal rehabilitation outcomes.
The nurse working in a critical care unit (CCU) is assigned the care of two clients, one with pneumonia who is being mechanically ventilated, and the other who had a thoracotomy yesterday and is reporting incisional pain. Which action(s) should the nurse perform first?
Sign Up or Login to view all the 125 Questions on this Exam
Join over 100,000+ nursing students using Naxlex’s science-backend flashcards, practice tests and expert solutions to improve their grades and reach their goals.
Sign Up Now
