RN101
Home of the Registered Nurses (RN) and
Licensed Practical Nurses (LPN)

SITUATION I

 

Question 1:

1. Prevent venous stasis or increase venous return, preventing deep vein thrombosis or pulmonary embolism

2. Increase muscle tone, coordination and independence

3. Improved gastrointestinal, genitourinary, and pulmonary functions

 

SITUATION II

 

Question 1:

Heat is not used immediately after injury because it increases circulation to the injured part, causing more swelling.

 

SITUATION III

 

Question 1:

Assess neurovascular signs

 

SITUATION IV

 

Question 1:

Handle the cast with the palms of the hands. Until a plaster cast has dried, placing pressure on the cast should be avoided to prevent creating areas inside the cast that could place pressure on the arm. 

 

Question 2:

Ice application for the first 24 hours after a fracture will help to reduce swelling and can be placed over the cast.

 

SITUATION V

 

Question 1:

Notify the physician immediately

 

SITUATION VI

 

Question 1:

Aspirin increases the possibility of postoperative bleeding or Aspirin impairs your ability to control bleeding.

 

SITUATION VII

 

Question 1:

1. Do weight bearing exercises (walking, swimming) – promotes bone growth

2. Eat foods rich in calcium and expose selt to the sun

 

Question 2:

1. Taken in the morning before meal and other meds

2. Take with full glass of water (8oz) 30 mins before 1st food

3. Patient to remain upright for 30 mins after dose (prevent esophageal irritation)

4. Advice to maintain good oral hygiene

 

SITUATION VIII

 

Question 1:

1. Lentils and 2. Sardines

 

SITUATION IX

 

Question 1:

To prevent straining at stools thereby preventing compression of the herniated disc.

 

Question 2:

Naprosyn is given twice a day as his regular pain medication and has an anti-inflammatory effect, while Acetaminophen is taken only when needed (PRN) if his naprosyn is not enough to control the pain.

 

SITUATION X

 

Question 1:

Yes, the restraints can be removed while the child is under their supervision. (or under adult supervision)

 

SITUATION XI

Question 1:

Avoid elevation to prevent flexion contractures of the right hip

 

SITUATION XII

 

Question 1:

"Let's talk about how you feel this surgery will affect you."

The initial nursing action should be to assess how the patient feels about the amputation and what the patient knows about the procedure and rehabilitation process.

 

Question 2:

Administer pain medication/analgesic (Dilaudid)

 

SITUATION XIII

 

Question 1:

1. Shorter

2. Adducted

3. Externally rotated

4. Asymmetry of the legs, loss of mobility, swelling or edema

 

Question 2:

1. Notify the physician

2. Take the patient's vital signs

3. Give pain medication as prescribe

4. Assess the patient pain (PQRST)

5. Immobilized patient’s leg or put patient on bed rest

6. Assess neurovascular signs

 

SITUATION XIV

 

Question 1:

1. Orient the patient to her environment

2. Divert her attention by watching TV or listening to music

3. Put pictures or personal things on her room that she recognized

4. Call a family member if possible

5. Have a sitter or PAB to accompany the patient or private service

6. Provide a quiet and calm environment

 

SITUATION XV

 

Question 1:

Use a bed exit safety monitoring device or bed alarm
A bed alarm or bed exit safety monitoring device is an intervention that can allow the client to feel independent and also alert the nursing and nursing staff when the client needs assistance. It is the most realistic answer that promotes client safety. 

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SITUATION XVI

 

Question 1:

1. Document the behavior(s) that require continued use of the restraints
2. Provide range-of-motion exercises when the restraints are removed
3. Orient the client
4. Assess the tightness of the restraints

Standards require documentation of the necessity for restraints. The implementation of range-of-motion exercises prevents joint stiffness and pain from disuse. Orienting the client helps the nurse determine the necessity of the restraint. 

 

Question 2:

Cover the cords with linens

 

SITUATION XVII

 

Question 1:

Pad the siderails

 

SITUATION XVIII

 

Question 1:

Monitor the patient frequently

 

SITUATION XIX

 

Question 1:

Hands are cool to the touch