Complex Care Flashcards

A practical nurse is caring for a client with end-stage heart failure who is on a low-sodium diet and furosemide 40 mg daily. The client's morning assessment reveals: weight gain of 1.8 kg overnight, JVD at 45°, crackles bilaterally to mid-lung fields, and SpO₂ of 90% on 2L/min nasal cannula. The client is DNR. Which action is the PN's PRIORITY?

Answer: Document findings, apply oxygen, and position the client in high-Fowler's while preparing for physician notification

The client is showing signs of acute decompensated heart failure (overnight weight gain, elevated JVD, worsening crackles, falling SpO₂). The immediate priority is optimizing respiratory status — high-Fowler's reduces venous return and eases breathing — while applying supplemental oxygen and preparing to notify the physician. Withholding the scheduled furosemide without a physician order is outside PN scope; administering a PRN diuretic without reassessment data and physician guidance is unsafe given the acuity. Oxygen increase alone without repositioning misses a key non-pharmacological intervention. The correct sequence is position + oxygen + notify.

A PN is assigned to a client 18 hours post-laparotomy for bowel resection with primary anastomosis. Vital signs are stable. During morning care, the client reports sudden severe abdominal pain rated 9/10, and the abdomen is rigid and board-like. Bowel sounds are absent in all four quadrants. The surgical drain has minimal dark-red output. Which finding is MOST concerning and warrants immediate escalation?

Answer: Sudden onset of rigid, board-like abdomen with severe pain

A rigid, board-like abdomen with sudden severe pain post-bowel-resection is a hallmark sign of anastomotic leak or bowel perforation causing peritonitis — a surgical emergency. Absent bowel sounds are expected in the first 24–72 hours post-laparotomy due to post-operative ileus and are not acutely alarming in isolation. Minimal dark-red drain output in the early post-operative period is within normal range. Pain in the immediate post-operative period is expected, but the sudden escalation combined with rigidity specifically signals an intra-abdominal catastrophe. The combination of rigidity + sudden severe pain requires immediate physician escalation.

A PN is caring for a 78-year-old client with Type 2 diabetes, CKD Stage 4, and peripheral arterial disease who is admitted with a non-healing left heel ulcer (Wagner Grade 3). The wound care order reads: 'Normal saline irrigation, apply silver sulfadiazine cream, cover with non-adherent dressing daily.' The client reports allergy to sulfa drugs. What is the MOST appropriate action?

Answer: Withhold the silver sulfadiazine, document the allergy concern, and notify the physician before proceeding

Silver sulfadiazine contains a sulfonamide moiety and is contraindicated in clients with a documented sulfa allergy due to cross-reactivity risk, which can include serious hypersensitivity reactions. The PN must withhold the medication — even a topical one — and notify the prescriber to obtain an alternative order before proceeding. Substituting an alternative agent without a physician order is outside PN scope of practice. Applying the medication regardless of allergy status violates the PN's duty to prevent harm. Completing the wound care without any topical agent (option D) protects the client partially but fails to communicate the allergy concern to the prescriber, which is a mandatory step.

A PN working in a complex continuing care setting is administering 08:00 medications to a client with myasthenia gravis who takes pyridostigmine 60 mg PO every 4 hours. The client reports feeling significantly weaker than usual and is having difficulty swallowing this morning. Which action reflects the MOST accurate clinical judgment?

Answer: Hold the dose, obtain oxygen saturation, assess respiratory rate and depth, and notify the physician

In myasthenia gravis, new-onset dysphagia and weakness can signal either myasthenic crisis (under-medication) or cholinergic crisis (over-medication from excess acetylcholinesterase inhibition). These crises are managed very differently — myasthenic crisis may require more pyridostigmine, while cholinergic crisis requires withholding it. Before administering or withholding the medication, the PN must first assess respiratory function (rate, depth, SpO₂), since respiratory muscle involvement is life-threatening, and immediately notify the physician to differentiate the crisis type. Administering the dose without assessment risks worsening a cholinergic crisis. Crushing pyridostigmine is appropriate for dysphagia in stable MG but not when the client has acute deterioration requiring physician assessment first.

A PN is caring for a client receiving palliative care for metastatic lung cancer who is on a continuous subcutaneous infusion of hydromorphone via syringe driver. The client's family member asks the PN to 'turn up the medication' because the client appears uncomfortable. The client is non-responsive but shows grimacing with repositioning and respiratory rate of 8 breaths/minute. What is the MOST appropriate response?

Answer: Conduct a thorough pain and distress assessment, document findings, and contact the palliative physician to review the infusion rate

Adjusting a continuous syringe driver rate requires a physician order — the PN cannot independently alter the rate based on family request alone. However, the scenario requires clinical judgment: the client shows signs of pain (grimacing) but also has a low respiratory rate (8 breaths/min), which may indicate opioid-induced respiratory depression that could worsen if the rate is increased. The PN must perform and document a complete assessment using a validated non-verbal pain tool, then contact the palliative care physician with objective findings to guide the decision. Administering a PRN bolus without assessing baseline respiratory status first is unsafe given the RR of 8. Simply refusing without escalating fails the client and family.

A PN is caring for a 65-year-old client admitted for decompensated liver cirrhosis with ascites and hepatic encephalopathy (Grade II). The client is currently receiving lactulose 30 mL PO TID. Morning labs return: sodium 128 mmol/L, potassium 3.1 mmol/L, creatinine 198 µmol/L, ammonia 112 µmol/L. The client becomes increasingly agitated and attempts to climb out of bed. Which intervention requires a physician order BEFORE the PN can implement it?

Answer: Applying a physical restraint to prevent the client from falling

Physical restraints are a regulated intervention in Canadian nursing practice and require a physician order before application, except in situations of immediate life-threatening emergency where documentation and physician notification must follow immediately. In this scenario, the client is agitated but not in immediate mortal danger from a single repositioning attempt, making least-restraint alternatives (alarms, family presence, reorientation, environmental modifications) the required first steps. Applying restraints without an order — even in hepatic encephalopathy — violates restraint legislation and professional standards. Side rail policy varies by jurisdiction (raising all 4 may be considered a restraint in some provinces). Reorientation and family engagement are independent nursing actions. Neurological documentation is a core PN function requiring no order.