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

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

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%

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