Question 40 - Pharmacological Therapies Practice Test for the NCLEX-PN Exam

Use the case study information provided to answer this question.

The nurse should recognize that ____ and ____ are the most important nursing interventions to take next after reviewing the vital signs from 0930.

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.

0800: Consulted with the RN regarding the client’s pain and vital signs. RN called the doctor to request additional pain medicine. The doctor wrote a new order for a patient-controlled analgesia (PCA) pump containing Morphine for client. Will set up intravenous PCA pump with RN present in room and educate client on use.

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

Vital Signs

  0800 0930
BP 178/96 86/54
T 99.2\(^\circ\)F 98.9\(^\circ\)F
HR 121 70
RR 22 6
SpO2 96% 88%

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