SWIFT RIVER MED SURG CLINICAL EXAM | QUESTIONS & 100% CORRECT ANSWERS (VERIFIED) | LATEST UPDATE | GRAD E A+ Estelle Hatcher, 31yr -old, r/o appendicitis, 1st day post -op appendectomy; No known allergies (N KA); Vital signs - Temp 101.2, BP 108/74, P 92, RR 20, SaO2 99%, alert and cooperative. Wound site clean, dry and intact NPO, NG -tube to low continuous suction. IV maintenance fluids with D5 1/2 NS with 20 KCL @ 125ml/hr in left forearm. Ambulates with min imal assistance. Family at beside. Dr. Sangerstien Correct Answer: Educational Needs Increased Fall Risk Increased Health Change Increased Pain Level Increased Psychological Needs Normal Sensorium Normal Ann Rails, 38 years old, c/o back pain, non -significant past medical history. No known allergies (NKA). Vital signs -BP 124/82, Temp 98.2, P 84, RR 22, SaO2 96%. Pain and numbness in legs for one week. Abnormal left leg weakness, gait unsteady, 5/10 on numeric pain scale. Neuro WNL, except leg pain upon movement. Activity as tolerated with assistance. D/C plan - decrease pain and restore normal gait. Regular diet. Dr. Suculo Correct Answer: Educational Needs Increased Fall Risk Increased Health Change In creased Pain Level Increased Psychological Needs Normal Sensorium Normal Virginia Smith, 57 -year-old who has elected to have a total mastectomy based on consultation with her surgeon, a total mastectomy removes all breast tissue but leaves all or most o f axillary lymph nodes and chest muscles intact. She is also to receive radiation, chemotherapy, and hormone therapy post operatively. She is with her physician. She is also investigating bone marrow transplantation. She has arrived in pre-op and about to have surgery this morning. Her husband and two grown children are also with her as she is prepared with gown and head cap awaiting transport to the operating room. She has IV access and has received a small dose of Valium to reduce apprehension. Temperatur e is 98.3, HR is 87, RR is16, BP is 121/74, PaO2 is 98%. Correct Answer: Educational Needs Increased Health Change Increased LOC Normal Pain Level Normal Psychological Needs Normal Safety Increased Lithia Monson, 93 years old, c/o head injury, r/o subdural hematoma. Hx of dementia, from nursing home, fall one day ago. No known allergies (NKA). Vital signs -Temp 97.2, BP 96/74, P 82, RR 20, SaO2 97%. Neuro - confusion to time and place, but oriented to self, speech clear, poor historian, did not recog nize son today which is new for her; Neuro assessment and vital signs q1 hr. Skin warm dry, bruises on forehead with small laceration. Increased fall risk. DSD (dry sterile dressing), forehead laceration clean and dry intact. 20ga. Hep -Lock in place left A C. GI WNL. Cardiovascular has pacer with rate of 82bpm on demand. Strict I&O, regular diet, intake 50%. Waist belt restraint PRN; family sitter at bedside, assist with bath. Dr. Altace Correct Answer: Educational Needs Increased Fall Risk Increased Health Change Increased Pain Level Increased Psychological Needs Increased Sensorium Increased Linda Pittmon, a 74 -year old female patient who is a noncompliant diabetic, and frequently stays at the local homeless shelter. She has been admitted to the floo r with complaints of numbness in her right foot and ankle. Mrs. Pittmon states she has had numbness for years but "now I can't feel it at all, and my toes don't look the right color.". Correct Answer: Educational Needs Increased