HESI Case Study - Hip Fracture and Cellulitis

Health Promotion and Maintenance, Techniques of Physical Assessment Ms. Black has been placed in her hospital bed upon arrival to the medical-surgical unit. Which intervention is most important for the charge nurse to verify as completed for her within the first hour? -A registered nurse (RN) performs and documents a comprehensive assessment. -A practical nurse (PN) inserts an intravenous catheter and collects blood samples. -The unlicensed assistive personnel (UAP) stocks the room with client care supplies. -A practical nurse (PN) does a comprehensive assessment and measures vital signs.

-A registered nurse (RN) performs and documents a comprehensive assessment. This assessment is required immediately after a hospital admission takes place and must be performed by an RN.

Physiological Integrity, Pharmacological and Parenteral Therapies, Pharmacological Pain Management The nurse has confirmed that Ms. Black knows how to use the pain scale and where the call light is located. The healthcare provider has written three prescriptions for pain management: Acetaminophen 650 mg PO every 6 hours as needed for mild pain Acetaminophen 1000 mg PO every 8 hours as needed for moderate pain Acetaminophen/hydrocodone 500 mg/5 mg PO 1 to 2 tablets every 6 hours as needed for moderate to severe pain Ms. Black reports to the nurse that her pain scale level is a 6 on a 0 to 10 scale. Which PRN medication should the nurse give her? -Acetaminophen 650 mg PO (two 325 mg tablets). -Acetaminophen 1000 mg PO (two 500 mg tablets). -Acetaminophen/hydrocodone 500 mg/5 mg PO 1 tablet. -Acetaminophen/hydrocodone 500 mg/5 mg PO 2 tablets.

-Acetaminophen/hydrocodone 500 mg/5 mg PO 1 tablet. The client's pain rating of a 6 of 10 is considered moderate to severe. Giving one tablet gives the nurse the ability to give another in 30 minutes to an hour, if the pain has not resolved satisfactorily. Acetaminophen/hydrocodone tablets take 30 to 60 minutes to take effect and have a half-life of 4 hours.

Physiological Integrity, Basic Care and Comfort, Mobility/Immobility The nurse is also concerned about venous thromboembolism occurring due to immobility. Which prescriptions written by the healthcare provider would satisfy the nurse who is concerned about preventing this complication of immobility? (Select all that apply.) -Apply sequential compression devices. -Apply a pair of compression stockings. -Institute a low protein and fat diet. -Ambulating her three times per day. -Give the daily prescribed enoxaparin. -Turning the client every two hours

-Apply sequential compression devices. -Apply a pair of compression stockings. -Ambulating her three times per day. -Give the daily prescribed enoxaparin. This prescription would be helpful for preventing venous thromboembolism by applying sequential, intermittent pressure to the legs and artificially milking the vessel structures of the lower extremities. This prescription would be helpful for preventing venous thromboembolism by applying gentle pressure to the veins in the legs. This prescription would be helpful for preventing venous thromboembolism. Although the client has a fractured hip, she could be carefully ambulated for short distances three times per day. She may initially be unwilling to cooperate due to pain. This prescription would be helpful for preventing venous thromboembolism by increasing the time it would take for her blood to form clots.

Physiological Integrity, Pharmacological and Parenteral Therapies, Medication Administration While the registered nurse (RN) is performing the admission assessment, the nurse notices that Ms. Black has a large bag full of her home medications, a suitcase full of clothes, a purse, and a cane. The practical nurse (PN) and the unlicensed assistive personnel (UAP) have come to assist the nurse. Which intervention is the best action for the nurse to take? -Have the UAP secure the client's purse with the hospital security team. -Tell the UAP to list of the client's belongings and verify the medications. -Ask the PN to record and verify which medications the client has been taking. -List and verify the medications and have the PN take the purse to security.

-Ask the PN to record and verify which medications the client has been taking. While the RN finishes the comprehensive admission assessment, the PN can list the medications the client brought with her to the hospital and verify them with the client so that the healthcare provider can review the list and decide if they should be continued during the hospitalization.

Physiological Integrity, Pharmacological and Parenteral Therapies, Pharmacological Pain Management Ms. Black's MRI report says that she has an incomplete left transverse sub-trochanteric hip fracture. Her community healthcare provider says that she has community-acquired methicillin-resistant staphylococcus aureus (MRSA) cellulitis. Ms. Black tells the nurse that she is having some pain in her left hip. Which action is most important when responding to the client's stated need? -Ensure that the client understands how the pain rating scale works. -Confirm that the client knows where the call light is and how to use it. -Assure the client that her pain experience will be respected and believed. -Ask the client which medications have reduced her pain in the past

-Assure the client that her pain experience will be respected and believed. When caring for clients with pain, it is the nurse's duty to recognize and relieve their pain. The nurse should advocate for and empower the client, and show compassion and respect for the client's experience.

Physiological Integrity, Basic Care and Comfort, Mobility/Immobility The client receives the second dose and reports a pain rating of 1 to 2 in an hour. The nurse documents the response in the electronic health record. There are also non-pharmacological methods for reducing pain and improving comfort for clients with an incomplete hip fracture. Which prescriptions would the nurse expect to maintain for Ms. Black? -Bed rest, elevate heal, and turn every 2 hours. -Balanced suspension skeletal traction. -Maintaining hip abduction traction. -Bed rest, knee immobilizer, and turn every hour.

-Bed rest, elevate heal, and turn every 2 hours. This client has suffered an incomplete, hairline fracture and will only need minimal body alignment for comfort.

Physiological Integrity, Pharmacological and Parenteral Therapies, Medication Administration The nurse has finished cleaning and treating the client's MRSA cellulitis. A new order has arrived in the electronic health record for this client. The first dose is due now. The new prescription reads, "Give 2 g vancomycin intravenously in 250 mL D5W over 1 hour." Which intervention is the most effective action for the nurse to perform first? -Call the healthcare provider to clarify the infusion duration. -Talk to the charge nurse to question this prescription. -Prepare to administer the medication as it was prescribed. -Administer the intravenous medication over 3 hours.

-Call the healthcare provider to clarify the infusion duration. Calling the healthcare provider to clarify the prescription details is the best action for the nurse to perform first. Administering 2 g of vancomycin at 250 mL/hour has been known to cause a toxic condition called "red man syndrome." The nurse should call the pharmacist and recommend a slower rate.

Physiological Integrity, Physiological Adaptation, Alterations in Body Systems Which type of MRSA infection does Ms. Black have? -Hospital acquired. -Actively acquired. -Community acquired. -Health care acquired.

-Community acquired. When the client was admitted to the hospital, she already had an MRSA infection.

Physiological Integrity, Basic Care and Comfort, Nutrition and Oral Hydration When the PN brings a food tray to Ms. Black, the PN notices that the client takes a very long time to finish chewing a single bite and then she spits the masticated food into a napkin. Which assessment finding would the PN expect to report to the nurse? -Xerostomia. -Malocclusions. -Periodontitis. -Edentulousness.

-Edentulousness. Having no teeth with which to chew will slow mastication significantly and some food will never quite become chewed enough for the client to feel safe about swallowing it.

Physiological Integrity, Physiological Adaptation, Pathophysiology Ms. Black fell and fractured her hip. Besides the fall, which progressive pathophysiological process should the nurse expect contributes to the cause of this fracture? -Reduction of muscle action potential in the sarcolemma. -Enhanced osteoclast formation with reduced apoptosis. -Diminished synovial membranes capacity and swelling. -Amplified osteoblast formation with reduced apoptosis.

-Enhanced osteoclast formation with reduced apoptosis. The client has a history of osteoporosis, which is a progressive process of enhanced osteoclast formation with reduced osteoclast apoptosis (programmed cell death) which leads to reduced bone density. Osteoclasts are macrophage-like cells that are specialized for bone resorption (reabsorbing bone back into circulation) and remodeling.

Physiological Integrity, Basic Care and Comfort, Mobility/Immobility The nurse is concerned about Ms. Black's skin integrity due to immobility. Which preventative measures should the nurse implement for this client? (Select all that apply.) -Frequent skin assessments. -Reorientation to time. -Meticulous skin care. -Reduced dietary calcium. -Adequate nutrition. -Frequent repositioning

-Frequent skin assessments. -Meticulous skin care. -Adequate nutrition. -Frequent repositioning Frequent skin assessments have shown to reduce the incidence of skin breakdown in clients with immobility. Meticulous skin care has shown to reduce skin breakdown in clients with immobility. Adequate nutrition has shown to reduce skin breakdown in clients with immobility. Frequent repositioning has shown to reduce skin breakdown in clients with immobility.

Physiological Integrity, Pharmacological and Parenteral Therapies, Dosage Calculation Ms. Black has had a good night sleep and day shift has begun. Her morning electrolyte laboratory tests show that she has a serum glucose level is 467 mg/dL. The nurse notifies the healthcare provider during morning rounds and a sliding scale insulin protocol is prescribed. Which action should the nurse perform next? -Give 15 units and check the finger stick glucose in an hour. -Be sure to notify the healthcare provider and give 15 units. -Perform a finger stick glucose and give the prescribed units. -Give 15 units and document this medication administration.

-Give 15 units and document this medication administration. The nurse should give 15 units of Regular insulin subcutaneously and document when this medication was given. Another nurse should also witness the dosage per hospital protocol.

Safe and Effective Care Environment, Management of Care, Referrals The nurse evaluates Ms. Black's referral needs in preparation for discharge to home. Which referrals will the nurse anticipate that the client needs after discharge from the hospital? (Select all that apply.) -Physical therapy. -Optometrist. -Audiologist. -Home health nursing. -Prosthodontist. -Diabetes educator.

-Home health nursing. -Prosthodontist. -Diabetes educator. This referral will be made for temporary assistance to support Ms. Black as she recovers from her injury. The client will need dentures to enjoy her food. A diabetes educator to help the client to adapt her diet to improve her health outcome.

Physiological Integrity, Reduction of Risk Potential, Diagnostic Tests The healthcare provider receives a report from radiology stating that the x-ray radiography findings of Ms. Black's leg are inconclusive. The healthcare provider recalls that her symptoms are consistent with a possible hip fracture and she has osteoporosis, so magnetic resonance imaging (MRI) is prescribed. The nurse is preparing the client for an MRI. Which actions are helpful for preparing the client for this diagnostic procedure? (Select all that apply.) -Inquire with the client about any history of anxiety in closed spaces. - Assess the client for any contraindications to having an MRI. -Assist the client with emptying her bladder before the procedure. -The client will need a 24-hour bowel prep and be NPO for 8 hours. -Explain the procedure to the client and obtain an informed consent. -Ask the client if she has ever had any allergies to shellfish or iodine

-Inquire with the client about any history of anxiety in closed spaces. - Assess the client for any contraindications to having an MRI. -Assist the client with emptying her bladder before the procedure. -Explain the procedure to the client and obtain an informed consent. The client will be placed in a metal tube during an MRI diagnostic procedure, and people who have claustrophobia may not be able to tolerate the closed space. The nurse could also recommend to the healthcare provider that an antianxiety medication will be needed. Contraindications to receiving an MRI are aneurism clips, plates, pacemaker, shrapnel, or any other metallic object. This action contributes to the client's comfort while in the MRI scanner. Explaining the procedure contributes to the client's comfort. Obtaining the informed consent is a collaborative action that assists the healthcare team with this client's care.

Physiological Integrity, Physiological Adaptation, Alterations in Body Systems The healthcare provider notifies the staff that the result of a skin culture taken 3 days ago in the clinic has come back as having methicillin-resistant staphylococcus aureus (MRSA) and the client is diagnosed as having MRSA cellulitis. Which assessment finding(s) would the nurse expect to observe? (Select all that apply.) -Bleeding. -Cool to touch. -Loss of function. -Fever. -Swelling. -Redness.

-Loss of function. -Fever. -Swelling. -Redness. The nurse would expect to find some loss of function due to swelling when assessing a client with MRSA cellulitis. The nurse would expect to find an abnormal and elevated body temperature when measuring the vital signs. The nurse would expect to find red swollen skin patches that are warm to the touch in a client with MRSA cellulitis. The nurse would expect to find red swollen skin patches that are warm to the touch in a client with MRSA cellulitis.

Physiological Integrity, Pharmacological and Parenteral Therapies, Pharmacological Pain Management About 45 minutes later, the nurse asks Ms. Black to rate her pain on a 0 to 10 scale and she rates her pain a 5, stating that the medication has "only touched it a little." Which response by the nurse would be most helpful intervention? -Give the acetaminophen 650 mg PO (two 325 mg tablets) for mild pain. -Offer the second acetaminophen/hydrocodone 500 mg/5 mg PO tablet. -Educate the client about opioid addiction and the need to avoid it. -Document the client's reply and return in 45 minutes to reassess her.

-Offer the second acetaminophen/hydrocodone 500 mg/5 mg PO tablet. Offering the second tablet is what the nurse should do in this situation. One tablet was not effective enough in 45 minutes.

Physiological Integrity, Basic Care and Comfort, Elimination Ms. Black activates the call light and the nurse comes into her room. She says that she has urinated in the bed and that she is embarrassed. This was an unexpected event. As the nurse and two unlicensed assistive personnel (UAPs) are cleaning up the client, she accidentally urinates again on the clean linens. Which intervention would be the most helpful for the nurse to perform? -Plan on instituting bladder training with this client. -Tell the healthcare provider that she is incontinent. -Clean her again and tell her not to be embarrassed. -Place an indwelling urinary catheter for the client.

-Plan on instituting bladder training with this client. The client should obtain a bedside commode to reduce ambulation or have a bedpan available and follow a bladder training program. For example, urinating first thing in the morning, before each meal, and before bedtime might be an effective routine for preventing incontinence accidents.

Safe and Effective Care Environment, Safety and Infection Control, Accident/Error/Injury Prevention As part of discharge planning, the nurse evaluates Ms. Black for injury prevention. Which of her characteristics especially influence safety and injury prevention effort for her? (Select all that apply.) -Polypharmacy. -Age. -History of falls. -Multiple illnesses. -Body weight. -Disorientation.

-Polypharmacy -Age. -History of falls. -Multiple illnesses. -Body weight. She arrived with a large bag of medications that had to be reconciled with the healthcare provider. She is 72 years old and she has osteoporosis. This hospitalization establishes that she has a fall history. She has diabetes, osteoporosis, hypertension, and obesity. She has a body mass index (BMI) of 37.8, which indicates obesity.

Physiological Integrity, Basic Care and Comfort, Nutrition and Oral Hydration Considering what is known about Ms. Black's condition so far, which diet would be the best selection for her? -Soft regular diet. -Low sodium diet. -Soft low fat, low sodium diet. -Liquid high protein diet.

-Soft low fat, low sodium diet. Ms. Black has diabetes and hypertension, and she has no teeth with which to chew her food, so a soft low fat, low sodium diet would be the best choice for her.

Safe and Effective Care Environment, Management of Care, Case Management So far, the nurse and the healthcare team have accomplished quite a lot for Ms. Black. Now documentation should be performed to communicate with the entire team giving care throughout the hospitalization and beyond. The nurse notes that documentation should be factual, accurate, complete, current, and organized. Which unexpected event occurring that day should initiate a new plan of care when updating Ms. Black's electronic health record? -Edentulousness. -Obesity. -Urinary incontinence. -Polypharmacy.

-Urinary incontinence. Urinary incontinence was an unexpected event that will require a bladder training program for improvement. This can be started in the hospital setting and continued at home for this client.

Physiological Integrity, Basic Care and Comfort, Mobility/Immobility The nurse is evaluating Ms. Black's potential for complications due to immobility. The client is immediately and especially susceptible to which complications? (Select all that apply.) -Venous thrombosis. -Constipation. -Peripheral neuropathy. -Pneumothorax. -Osteoporosis. -Deconditioning.

-Venous thrombosis. -Constipation. -Osteoporosis. -Deconditioning. Venous thromboembolism is caused by venous thrombosis and develops due to blood pooling in the lower extremities. This condition is frequently a complication of immobility. The client is immobile, and she is taking opioid pain medication, which slows peristalsis. Ms. Black already has osteoporosis. She will be immobile for several days, so it may worsen. Muscle deconditioning (weakening) will eventually and quickly occur with immobility.

Physiological Integrity, Physiological Adaptation, Alterations in Body Systems The unlicensed assistive personnel (UAP) is assisting Ms. Black with a bed bath. Which action by the UAP requires the nurse to intervene? -Wash all infected areas of skin before uninfected areas. -Putting washcloths, towels, and bedding in an isolation bag. -Washing hands with antimicrobial soap after the bath. -Changing washcloths often when cleaning the infected area.

-Wash all infected areas of skin before uninfected areas. This action will spread the MRSA infection to the rest of the client's skin.

Physiological Integrity, Physiological Adaptation, Alterations in Body Systems When the nurse is giving care to a client with methicillin-resistant staphylococcus aureus (MRSA) cellulitis, which safety precautions should be observed? (Select all that apply.) -Wearing gown, gloves, and mask when giving wound care. -Place a powered air purifying respirator on the client. -Ensure that the client is assigned to a private room. -Perform frequent hand washing with antimicrobial soap. -Ensure that the client's room has negative pressure.

-Wearing gown, gloves, and mask when giving wound care. -Ensure that the client is assigned to a private room. -Perform frequent hand washing with antimicrobial soap. Wear gown, gloves, and mask to prevent spreading infection when providing wound care is an important part of giving care to clients with MRSA cellulitis. Ensuring that the client with MRSA cellulitis is assigned to a private room is necessary to prevent spreading the infection. Alternatively, if there are no private rooms available, the client should be placed in a room with a client who has the same infection. Cleaning the hands frequently with antimicrobial soap to prevent spreading infection is an important part of giving care to clients with MRSA cellulitis.

Physiological Integrity, Pharmacological and Parenteral Therapies, Dosage Calculation The nurse is preparing to give 2 g of intravenous vancomycin in 250 mL D5W over 2 hours. What is the flow rate in mL per hour that should be programmed into the infusion pump? (Enter numerical value only. If rounding is required, round to the whole number.)

250mL / 2hrs = 125 mL/hr

Ms. Black arrives on a stretcher to the medical-surgical unit. The unit is busy, and the charge nurse tells the Emergency Department unlicensed assistive personnel (UAP) to place her in room 3. Which action requires the nurse to intervene immediately? -Staff keep the client's weight close to their center of gravity when lifting. -Four people transfer the client from the stretcher to the bed at waist height. -The UAP raises the bed and attempts to pull the client onto it with bed sheet. -The bed is raised to the height of the stretcher before initiating the transfer.

The UAP raises the bed and attempts to pull the client onto it with bed sheet. This client weighs 220 lbs (100 kgs). This transfer method places the client and the UAP at risk for injury. The client is at risk for skin sheering from the bed sheet and falling. The UAP is at risk for a back injury because their weight is transferred away from the UAP's center of gravity.