Question 36 - Pharmacological Therapies Practice Test for the NCLEX-PN Exam

Use the case study information provided to answer this question.

Which of the following would alert you to acute, uncontrolled pain in this client?
Select all that apply.

A. BP 178/96
B. “Client is restless and diaphoretic.”
C. SpO2 96%
D. HR 121
E. mottled right foot
F. RR 22

Intro to case:

You are assigned to float to the orthopedic surgical floor as an LPN. One of your clients is a 48-year-old female who was admitted to the floor yesterday after a motor vehicle accident (MVA) in which she fractured her pelvis and right femur. She had emergency surgery last night and her anesthesia has worn off.

Nurse’s Notes

0730: Client is in bed fidgeting and constantly trying to change positions stating, “no matter what position I’m in, everything hurts.” Client is restless and diaphoretic. She states her pain level is “10” on the 1-10 numerical pain scale. Client’s last IV Dilaudid was given at 0630.

History and Physical

Body System Findings
Cardiovascular Hx of mild hypertension, varicose veins, and
Raynaud’s phenomenon. Capillary refill > 3 sec,
hypertensive, mottling noted to right foot.
Integumentary Hx of squamous cell carcinoma. Right leg incision
clean, dry, intact, and approximated. No signs of
infection noted.
Neurological AAOX4, PERRLA, but notes tingling in right foot
since her accident.
Respiratory Hx of 1/2 PPD smoker. Quit smoking 1 month ago.
Lungs clear. Client is tachypneic.
Musculoskeletal Hx of osteoarthritis, tendinitis of both ankles.
Right pelvic fracture and right femur fracture
from MVA- surgically repaired by external fixation
yesterday.

Vital Signs

  0800
BP 178/96
T 99.2\(^\circ\)F
HR 121
RR 22
SpO2 96%

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