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Bsn 266-rn medical-surgical- 35504- nightingale college proctored exam
Total Questions : 57
Showing 10 questions, Sign in for moreA 68-year-old male, with a history of bilateral total hip arthroplasty two years ago, presents to the emergency department (ED) by ambulance. The client reports he simply slipped today and did not feel lightheaded or dizzy before the fall. The client reports he returned home from the store and was putting his groceries away. He dropped a can and bent over to pick it up. He lost his balance and fell face-forward, hitting his head on the wall and his left shoulder on the floor. Reports pain mainly in his shoulder. However, he also notes pain in his right knee. Additionally, the client reports he feels nauseated and tired.
1820
Client is resting in bed, grimacing. Vital signs assessed. Reports intense pain and the inability to move his left arm. He is guarded. Shoulder swelling and bruising are present. Left arm is cool to the touch. Collarbone appears out of alignment on the left side.
1820
Temperature: 98.1° F (36.7" C) orally
Heart rate: 88 beats/minute
Respirations: 18 breaths/minute
Blood pressure: 136/90 mm Hg
Oxygen saturation: 95% on room air
Pain: 10 on a 0 to 10 scale, sharp, constant pain in the left arm: pain rating of 3 on a 0 to 10 scale, dull, achy pain in the right knee
Weight: 344 lb (156.1 kg)
Height: 6 ft 2 in (182.8 cm)
Body mass index (BMI) is 46.67 kg/m2 (normal 18 to 24.9 kg/m3)
The nurse considers the brief interaction with the client and the triage report. Which finding(s) should the nurse investigate further? Select all that apply.
A 68-year-old male, with a history of bilateral total hip arthroplasty two years ago, presents to the emergency department (ED) by ambulance. The client reports he simply slipped today and did not feel lightheaded or dizzy before the fall. The client reports he returned home from the store and was putting his groceries away. He dropped a can and bent over to pick it up. He lost his balance and fell face-forward, hitting his head on the wall and his left shoulder on the floor. Reports pain mainly in his shoulder. However, he also notes pain in his right knee. Additionally, the client reports he feels nauseated and tired.
1820
Client is resting in bed, grimacing. Vital signs assessed. Reports intense pain and the inability to move his left arm. He is guarded. Shoulder swelling and bruising are present. Left arm is cool to the touch. Collarbone appears out of alignment on the left side.
1035
Peripheral IV (PIV) access is initiated, 20 gauge, in the client's right forearm. Assessment completed.
Assessment
Neurological: Pupils equal, round, reactive to light accommodations (PERRLA), Oriented to person, place, time, and situation. Decreased sensation noted in left forearm to fingertips.
Cardiovascular: Normal heart sounds of S, and S. Bilateral pedal pulses and right radial pulse are 2+ while left radial is
Respiratory: Clear lung sounds in all fields.
Musculoskeletal: Normal strength observed in lower extremities. Minimal pain on palpation noted in right knee. The client can still flex and extend his right leg. 1+ strength noted in the left upper extremity and 3+ strength noted in the right upper extremity. Diffuse pain noted with and without palpation on the left shoulder, and pain reported extending from the left shoulder into the neck. 3+ swelling is noted on the left shoulder and 1+ swelling on the right knee. No pain noted upon assessment of right shoulder and left knee.
Gastrointestinal: Abdomen is soft, nondistended and nontender.
Genitourinary: Last bowel movement reported today. The client denies difficulty with urination.
Integumentary: The left arm is cool to touch. Bruising is noted on the left upper arm; bruise area is 0.79 in (3 cm) by 1.97 in (5 cm) area of blood noted on the bandage. The left arm is warm to touch. The client's left shoulder and collarbone are symmetric.
1820
Temperature: 98.1° F (36.7" C) orally
Heart rate: 88 beats/minute
Respirations: 18 breaths/minute
Blood pressure: 136/90 mm Hg
Oxygen saturation: 95% on room air
Pain: 10 on a 0 to 10 scale, sharp, constant pain in the left arm: pain rating of 3 on a 0 to 10 scale, dull, achy pain in the right knee
Weight: 344 lb (156.1 kg)
Height: 6 ft 2 in (182.8 cm)
Body mass index (BMI) is 46.67 kg/m2 (normal 18 to 24.9 kg/m3)
1830
Initiate peripheral IV (PIV) access
X-ray of left shoulder and right knee, STAT
Computed tomography (CT) of brain, STAT
For each assessment finding, click to indicate whether the findings from the client's assessment are generally associated with rotator cuff injury and/or humeral fracture. Each column must have at least one response selected.
Explanation
Rotator Cuff Injury:
• 1+ strength in left upper extremity
• Pain with movement
• Decreased range of motion
Humeral Fracture:
• Reduced pulse distal to injury
• Coolness of skin
Rationale
• 1+ strength in left upper extremity: Weakness or limited strength in the affected arm is characteristic of rotator cuff injuries due to tendon or muscle damage affecting shoulder abduction or flexion. The client’s minimal ability to move the arm against resistance indicates compromised rotator cuff function rather than complete bone disruption.
• Pain with movement: Pain that worsens with shoulder movement is typical of rotator cuff tears or strains. Tendon involvement leads to pain when lifting, rotating, or performing overhead motions. This finding aligns more with soft tissue injury than fracture, which may present with constant severe pain even at rest.
• Decreased range of motion: Limited ability to move the shoulder actively or passively is a hallmark of rotator cuff pathology. Tendon inflammation, tearing, or muscle injury restricts motion without necessarily affecting vascular status. This differentiates it from fractures, where motion may be severely limited by pain or mechanical instability.
• Reduced pulse distal to injury: A fracture of the humerus can compromise vascular structures, leading to decreased distal pulses. The left radial pulse may be diminished due to swelling, vessel injury, or nerve compression. This is a red flag for fracture requiring urgent evaluation.
• Coolness of skin: Coolness distal to the injury indicates impaired circulation, which can occur with fractures due to swelling, hematoma, or neurovascular compromise. This sign suggests bone injury affecting blood flow rather than isolated soft tissue damage from a rotator cuff tear.
A 68-year-old male, with a history of bilateral total hip arthroplasty two years ago, presents to the emergency department (ED) by ambulance. The client reports he simply slipped today and did not feel lightheaded or dizzy before the fall. The client reports he returned home from the store and was putting his groceries away. He dropped a can and bent over to pick it up. He lost his balance and fell face-forward, hitting his head on the wall and his left shoulder on the floor. Reports pain mainly in his shoulder. However, he also notes pain in his right knee. Additionally, the client reports he feels nauseated and tired.
1820
Client is resting in bed, grimacing. Vital signs assessed. Reports intense pain and the inability to move his left arm. He is guarded. Shoulder swelling and bruising are present. Left arm is cool to the touch. Collarbone appears out of alignment on the left side.
1035
Peripheral IV (PIV) access is initiated, 20 gauge, in the client's right forearm. Assessment completed.
Assessment
Neurological: Pupils equal, round, reactive to light accommodations (PERRLA), Oriented to person, place, time, and situation. Decreased sensation noted in left forearm to fingertips.
Cardiovascular: Normal heart sounds of S, and S. Bilateral pedal pulses and right radial pulse are 2+ while left radial is
Respiratory: Clear lung sounds in all fields.
Musculoskeletal: Normal strength observed in lower extremities. Minimal pain on palpation noted in right knee. The client can still flex and extend his right leg. 1+ strength noted in the left upper extremity and 3+ strength noted in the right upper extremity. Diffuse pain noted with and without palpation on the left shoulder, and pain reported extending from the left shoulder into the neck. 3+ swelling is noted on the left shoulder and 1+ swelling on the right knee. No pain noted upon assessment of right shoulder and left knee.
Gastrointestinal: Abdomen is soft, nondistended and nontender.
Genitourinary: Last bowel movement reported today. The client denies difficulty with urination.
Integumentary: The left arm is cool to touch. Bruising is noted on the left upper arm; bruise area is 0.79 in (3 cm) by 1.97 in (5 cm) area of blood noted on the bandage. The left arm is warm to touch. The client's left shoulder and collarbone are symmetric.
1820
Temperature: 98.1° F (36.7" C) orally
Heart rate: 88 beats/minute
Respirations: 18 breaths/minute
Blood pressure: 136/90 mm Hg
Oxygen saturation: 95% on room air
Pain: 10 on a 0 to 10 scale, sharp, constant pain in the left arm: pain rating of 3 on a 0 to 10 scale, dull, achy pain in the right knee
Weight: 344 lb (156.1 kg)
Height: 6 ft 2 in (182.8 cm)
Body mass index (BMI) is 46.67 kg/m2 (normal 18 to 24.9 kg/m3)
1830
Initiate peripheral IV (PIV) access
X-ray of left shoulder and right knee, STAT
Computed tomography (CT) of brain, STAT
Choose the most likely options for the information missing from the statements by selecting from the lists of options provided.
Based on the client's condition, the priority need will be to address
Explanation
• Compartment syndrome
The client’s left upper extremity presents with severe pain, cool temperature, swelling, decreased radial pulse, and decreased sensation—classic indicators of impaired perfusion. These findings, combined with inability to move the limb and escalating pain, suggest rising pressure within the compartment. Compartment syndrome is limb threatening and requires immediate priority intervention to prevent irreversible neurovascular damage.
• Venous thromboembolism
The client has immobility due to extreme pain, obesity with a BMI of 46.67, and reduced use of the affected limb, all of which markedly increase VTE risk. Trauma and limited mobility compound venous stasis, making preventive interventions essential. Without prophylaxis, he is vulnerable to developing DVT or pulmonary embolism during hospitalization.
• Mobility
Although restricted mobility is present, it is not the immediate life threatening concern. Addressing mobility comes after stabilizing neurovascular function. Limited activity is anticipated with fractures or shoulder injury and is better considered a secondary focus. Prioritizing life or limb threatening complications, such as compartment syndrome, takes precedence over movement optimization.
• Swelling
Swelling is significant but represents a symptom rather than the underlying critical threat. It contributes to compartment syndrome but is not itself the primary clinical priority. Treating swelling alone does not address the deeper perfusion issue and would not sufficiently prevent neurovascular compromise. It therefore cannot replace the need to focus on compartment pressure.
• Pain
The client has intense pain, but pain control does not supersede an emergent complication threatening tissue viability. Severe pain in this context is a symptom suggestive of compartment syndrome rather than the standalone priority. Treating pain without identifying the cause would risk delaying essential interventions.
• Fat embolism syndrome
Fat embolism is associated with long bone fractures, especially femur or pelvic injuries, which this client does not present with. His symptoms do not include respiratory distress, petechiae, or neurological changes. The concern is less relevant than his true acute risks, and preventive measures for VTE are more appropriate based on his immobility and obesity.
A 68-year-old male, with a history of bilateral total hip arthroplasty two years ago, presents to the emergency department (ED) by ambulance. The client reports he simply slipped today and did not feel lightheaded or dizzy before the fall. The client reports he returned home from the store and was putting his groceries away. He dropped a can and bent over to pick it up. He lost his balance and fell face-forward, hitting his head on the wall and his left shoulder on the floor. Reports pain mainly in his shoulder. However, he also notes pain in his right knee. Additionally, the client reports he feels nauseated and tired.
1820
Client is resting in bed, grimacing. Vital signs assessed. Reports intense pain and the inability to move his left arm. He is guarded. Shoulder swelling and bruising are present. Left arm is cool to the touch. Collarbone appears out of alignment on the left side.
1035
Peripheral IV (PIV) access is initiated, 20 gauge, in the client's right forearm. Assessment completed.
Assessment
Neurological: Pupils equal, round, reactive to light accommodations (PERRLA), Oriented to person, place, time, and situation. Decreased sensation noted in left forearm to fingertips.
Cardiovascular: Normal heart sounds of S, and S. Bilateral pedal pulses and right radial pulse are 2+ while left radial is
Respiratory: Clear lung sounds in all fields.
Musculoskeletal: Normal strength observed in lower extremities. Minimal pain on palpation noted in right knee. The client can still flex and extend his right leg. 1+ strength noted in the left upper extremity and 3+ strength noted in the right upper extremity. Diffuse pain noted with and without palpation on the left shoulder, and pain reported extending from the left shoulder into the neck. 3+ swelling is noted on the left shoulder and 1+ swelling on the right knee. No pain noted upon assessment of right shoulder and left knee.
Gastrointestinal: Abdomen is soft, nondistended and nontender.
Genitourinary: Last bowel movement reported today. The client denies difficulty with urination.
Integumentary: The left arm is cool to touch. Bruising is noted on the left upper arm; bruise area is 0.79 in (3 cm) by 1.97 in (5 cm) area of blood noted on the bandage. The left arm is warm to touch. The client's left shoulder and collarbone are symmetric.
1820
Temperature: 98.1° F (36.7" C) orally
Heart rate: 88 beats/minute
Respirations: 18 breaths/minute
Blood pressure: 136/90 mm Hg
Oxygen saturation: 95% on room air
Pain: 10 on a 0 to 10 scale, sharp, constant pain in the left arm: pain rating of 3 on a 0 to 10 scale, dull, achy pain in the right knee
Weight: 344 lb (156.1 kg)
Height: 6 ft 2 in (182.8 cm)
Body mass index (BMI) is 46.67 kg/m2 (normal 18 to 24.9 kg/m3)
1830
Initiate peripheral IV (PIV) access
X-ray of left shoulder and right knee, STAT
Computed tomography (CT) of brain, STAT
1900
Morphine 2 mg IV push (IVP) times one now
Oxycodone 7.5 mg PO every 4 hours, PRN for pain greater than 5 on 0 to 10 scale
Acetaminophen 500 mg PO every 4 hours, PRN for pain greater than 2 on 0 to 10 scale
The nurse addresses the client's pain and plans interventions to reduce further complications.
Choose the most likely options for the information missing from the statements by selecting from the lists of options provided.
The nurse monitors the client's
Explanation
• Respirations
Morphine can depress the respiratory center, so monitoring respirations is essential to detect early signs of hypoventilation. The client is receiving an IV opioid, which has a rapid onset and increases the risk of respiratory suppression. Close monitoring ensures prompt intervention if breathing becomes shallow or slows. Pain relief must be balanced with safety during opioid administration.
• Ice application to the shoulder
Ice helps reduce swelling and inflammation associated with acute musculoskeletal injuries. The client has significant shoulder swelling, bruising, and suspected trauma that benefits from cold therapy. Applying ice limits additional tissue damage and decreases pain by slowing nerve conduction. It supports early-stage injury management while awaiting diagnostic imaging.
• Heart rate
Although morphine can affect heart rate, monitoring respirations is the primary safety action due to the greater risk of respiratory depression. The client’s heart rate is stable, and no cardiovascular instability is reported. Respiratory monitoring provides more immediate information regarding opioid effects. Priority aligns with airway and breathing safety.
• Mood alterations
Mood monitoring is not a priority after opioid administration, as it does not directly relate to morphine’s physiological risks. The client's immediate concerns involve acute injury, pain, and potential neurovascular compromise, which require physical assessments. Mood becomes relevant later in the overall plan but not in this specific context. Observation must focus on possible respiratory suppression.
• Warm compressors
Heat can worsen swelling and increase blood flow to an already injured, swollen area. The client has acute trauma with significant swelling that requires vasoconstriction, not vasodilation. Warmth may also increase pain and exacerbate soft tissue injury. Cold therapy is safer and more appropriate in the acute phase.
• Antibiotics
There is no indication of infection, open wound requiring prophylaxis, or systemic signs of bacterial illness. The client’s injuries appear musculoskeletal rather than infectious, and imaging is underway to confirm damage. Antibiotics would not address swelling or pain and may expose the client to unnecessary side effects. Treatment should target trauma-related inflammation instead.
After teaching a male client with chronic kidney disease (CKD) about therapeutic diet for his condition, the nurse provides the client with a menu to make breakfast selections. Which food choice(s) by the client indicate that the teaching was effective? Select all that apply.
The nurse is caring for a client with urolithiasis who reports severe flank and abdominal pain, Which action should the nurse implement?
A client with a C-7 spinal cord injury (SCI) is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor?
A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse?
The client is a 65-year-old male admitted to the medical surgical unit after a total cholecystectomy. He has past medical history of hypertension, heart failure, type 1 diabetes mellitus, cholelithiasis, and cigarette smoking 1 pack a day for 20 years. The client has been reporting pain that is, "Barely relieved by pain medication." He had not been able to use the incentive spirometer every hour as prescribed because, "It is too painful to take a deep breath."
Postoperative Day (POD) 2
The client has a fever. He says he had a shaking chill and a productive cough episode early morning but didn't want to bother the night nurse. He says that he cannot lie down to sleep because, "I cannot stop coughing." He also reports pain to the right side of his chest rating it 6 on a scale of 0 to 10.
Temperature: 99° F (37.2" C) orally
Heart rate: 88 beats/minute
Respirations: 24 breaths/minute
Blood pressure: 148/80 mm Hg
Oxygen saturation: 92% on room air
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should toke to address that condition, and two parameters the nurse should monitor to assess the client's progress.
Explanation
Select 1:
- Pneumonia
Actions to Take:
• Obtain a sputum sample for culture and sensitivity (C&S)
• Obtain a prescription for a chest x-ray and antibiotic therapy
Parameters to Monitor:
• Respiratory status
• Blood pressure, heart rate, respiratory rate, oxygen saturation, temperature
Rationale
• Pneumonia
The client presents with fever, productive cough, right-sided chest pain, and difficulty lying down due to coughing. Shallow breathing from postoperative pain and poor use of the incentive spirometer increases the risk of alveolar collapse and infection. The productive cough and mild hypoxia (oxygen saturation 92%) suggest bacterial involvement, making pneumonia the most likely condition.
• Obtain a sputum sample for culture and sensitivity (C&S)
Collecting a sputum sample identifies the causative organism and guides targeted antibiotic therapy. This is critical for appropriate management of postoperative pneumonia, ensuring effective treatment and minimizing complications. Early identification can prevent progression to sepsis and improves recovery outcomes.
• Obtain a prescription for a chest x-ray and antibiotic therapy
A chest x-ray confirms the presence, location, and extent of pulmonary infiltrates. Early initiation of empiric antibiotics while awaiting culture results helps reduce infection severity. These actions address both diagnosis and treatment, which is essential for timely intervention in postoperative patients.
• Respiratory status
Monitoring respiratory status, including rate, depth, and ease of breathing, assesses effectiveness of lung expansion and identifies early complications such as hypoxia or atelectasis. Frequent assessment helps guide interventions like incentive spirometry, supplemental oxygen, or positioning to improve ventilation. Changes in lung sounds or cough effectiveness indicate progression or improvement.
• Blood pressure, heart rate, respiratory rate, oxygen saturation, temperature
Vital signs reflect systemic response to infection and oxygenation status. Monitoring these parameters allows early detection of complications like sepsis or worsening hypoxia. Trends in temperature, oxygen saturation, and hemodynamics provide critical data on treatment efficacy and guide further interventions.
• Sepsis
While the client has mild fever and tachypnea, there is no evidence of hypotension, altered mental status, or severe systemic inflammatory response that would indicate sepsis. The infection appears localized to the lungs, and vital signs do not reflect the severity required for a sepsis diagnosis at this point.
• Pneumothorax
The client does not report sudden unilateral chest pain, dyspnea at rest, or absent breath sounds on one side, which are characteristic of pneumothorax. The cough and fever suggest infection rather than collapsed lung. The lung auscultation and oxygen saturation indicate hypoxia from pneumonia rather than air in the pleural space.
• Hypoxemia
Although oxygen saturation is slightly low at 92%, hypoxemia is a parameter rather than a primary condition. It is a manifestation of pneumonia and shallow breathing rather than an isolated diagnosis. Monitoring and interventions focus on addressing the underlying infection to correct oxygenation.
• Place client on supplemental oxygen
While oxygen may be needed if hypoxia worsens, immediate priority is to diagnose and treat the infection. Supplemental oxygen alone does not treat the cause and may mask clinical deterioration if used without addressing pneumonia. Oxygen therapy is adjunctive to antimicrobial and supportive care.
• Obtain a repeat blood glucose STAT
Although the client has type 1 diabetes, there is no indication of hyperglycemia or hypoglycemia contributing to the current respiratory symptoms. Blood glucose assessment is important for overall management but is not directly related to pneumonia risk or immediate respiratory status.
• Perform a 12-lead electrocardiogram (ECG)
No cardiac symptoms such as chest pressure radiating to the arm, arrhythmias, or ischemic changes are reported. ECG would not aid in diagnosing the current respiratory condition and is not a priority intervention for pneumonia.
• Surgical site for inflammation
The incision site appears intact without redness, drainage, or swelling. There is no evidence of surgical site infection contributing to the client’s fever or symptoms. Monitoring the wound is routine but does not provide immediate information about the pneumonia risk or progression.
• Neurologic status
The client is alert and oriented with no signs of confusion or altered consciousness. Neurologic monitoring is not a priority in assessing postoperative pneumonia risk unless systemic infection or hypoxia worsens. Immediate focus should remain on respiratory function.
• Input and urinary output
There are no indications of fluid imbalance or renal compromise in this client at present. Monitoring output is important for overall postoperative care but does not provide specific information on pneumonia or respiratory status.
The healthcare provider prescribes streptomycin 300 mg IM every 12 hours for a client with tuberculosis. The available vial is labeled, Streptomycin 1 gram/2.5 mL. How many milliliters should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)
Explanation
Calculation:
- Identify the ordered dose and available concentration
Ordered Dose: 300 mg
Available Concentration: 1 g (1000 mg) / 2.5 mL
- Calculate the volume to administer
Volume to administer = (Ordered Dose ÷ Concentration) × Volume of Concentration
Volume to administer = (300 ÷ 1000) × 2.5
Volume to administer = 0.3 × 2.5
Volume to administer = 0.75 mL
- Round to the nearest tenth
Volume to administer = 0.8 mL
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