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Answer the questions of each case Case 1: Helen Jackson, a…
Answer the questions of each case
Case 1:
Helen Jackson, a 63-year-old Caucasian female, arrives at the surgery center for her
preoperative appointment. She is scheduled to have surgery on her left femur due to bone cancer.
During preoperative screening, the nurse recognizes abnormal vital signs (HR 108, RR 24, BP 124/70 and
T 98.6) and lab tests, and patient reporting not feeling like eating for a while.
Preoperative teaching includes evaluating the client’s deep breathing techniques and responding to the
client’s concerns about getting a pressure sore and overdosing on pain medication through a PCA pump.
A week later, Ms. Jackson arrives 3 hours before her scheduled surgery. The nurse confirms the client’s
NPO status and the markings on the client’s hips and takes action in response to the unsigned surgical
consent form. In the Operating Room, the nurse establishes a priority diagnosis and calls a time out. In
the immediate postoperative period, the nurse positions the client and documents the appearance of
the surgical dressing. When Ms. Jackson is transferred to the surgical unit, the nurse first needs to
calculate an IV infusion drop rate, and when an infusion pump becomes available, an IV rate in ml/hour.
What clinical manifestations does the patient have?
What would be the priority Nursing Diagnosis (choose one).
Interpret the ABG?
What symptoms does the patient have specific to the ABG abnormality?
What treatment would you expect based on the problem?
What nursing interventions would you expect?
Case 2
Nick Davis, a 42-year-old male, is accompanied to the emergency room by the police who found
him standing on a bridge, threatening to jump. Nick has a strong odor of alcohol on his breath. Nick is
angry and uncooperative. He states that he has been feeling sad lately and drinks alcohol to help him
cope with his feelings. He sleeps 5 to 6 hours a night and reports a poor appetite, chronic diarrhea with
significant weight loss in the past month. VS, T-97.9, HR 52, R 16, BP 100/56.
The nurse recognizes Nick’s risk for self-harm. Nick is admitted to the Crisis Care Unit, where the nurse
reviews personal items he can have in his room. Imbalanced nutrition is identified as a priority problem.
The nurse implements care during alcohol detoxification: setting goals, assessing vital signs, and
monitoring symptoms using a withdrawal assessment tool (CIWA-AR). The nurse administers Lorazepam
(Ativan) for alcohol withdrawal symptoms .
What clinical manifestations does the patient have?
What would be the priority Nursing Diagnosis (choose one).
Interpret the ABG?
What symptoms does the patient have specific to the ABG abnormality?
What treatment would you expect based on the problem?
What nursing interventions would you expect?
Case 3
Bert Graham, a 63-year-old male, visits the healthcare clinic complaining of increasing fatigue
and difficulty breathing. Physical assessment findings include a rapid, irregular heart rate of 138 beats
per minute, BP of 140/86, and a respiratory rate of 28. His breath sounds are clear with fine crackles in
the bases bilaterally. He has positive jugular vein distention (JVD) bilaterally and 1+ pitting edema of his
ankles bilaterally. His initial medical diagnosis is heart failure (HF). Bert is admitted to the acute care
facility.
The nurse considers risk factors and symptoms that differentiate right and left-sided failure. The nurse
recognizes atrial fibrillation on Bert’s ECG monitor and implements priority care. The nurse implements
care and teaching related to Bert’s prescriptions for captopril, ducosate sodium, carvedilol, furosemide,
and digoxin. Priority nursing diagnoses are identified and related nursing care is planned.
What clinical manifestations does the patient have?
What would be the priority Nursing Diagnosis (choose one).
Interpret the ABG?
What symptoms does the patient have specific to the ABG abnormality?
What treatment would you expect based on the problem?
What nursing interventions would you expect?
