CPNRE Complex Care 2 — Questions and Answers
Question 1: A client post-abdominal surgery reports sudden severe abdominal pain with board-like rigidity. What is the priority nursing action?
- Administer analgesic and reassess in 30 minutes
- Position in semi-Fowlers and notify the physician immediately (Correct answer)
- Apply warm compress and continue monitoring
- Document and report at end of shift
Correct answer: Position in semi-Fowlers and notify the physician immediately
Sudden severe pain with abdominal rigidity post-surgery suggests peritonitis or anastomotic leak requiring immediate medical intervention.
Board-like rigidity with sudden severe pain in a post-surgical client signals possible peritonitis, anastomotic leak, internal hemorrhage, or bowel obstruction. Priority: notify the physician immediately with SBAR; keep client NPO; establish IV access; monitor vital signs continuously; prepare for possible return to surgery. This is a life-threatening surgical emergency per Canadian perioperative nursing standards.
Question 2: A client with Type 1 diabetes has blood glucose 2.8 mmol/L with diaphoresis and trembling. Which intervention has priority?
- Administer insulin as ordered
- Give 15 grams of fast-acting carbohydrate if the client can swallow safely (Correct answer)
- Start IV normal saline immediately
- Hold all insulin until glucose normalizes
Correct answer: Give 15 grams of fast-acting carbohydrate if the client can swallow safely
A conscious client with symptomatic hypoglycemia receives 15g fast-acting carbohydrate first (15-15 rule).
Blood glucose 2.8 mmol/L with symptoms is hypoglycemia. For a conscious client: give 15g fast-acting carbohydrate (4 glucose tablets, 125 mL juice, or 15 mL glucose gel); recheck in 15 minutes; repeat if still below 4.0 mmol/L; follow with complex carbohydrate if next meal is >1 hour away. This is Diabetes Canada's 15-15 rule. Insulin is absolutely contraindicated in hypoglycemia.
Question 3: A client with chronic renal failure on a potassium-restricted diet selects which food that requires correction?
- White rice with butter
- Orange juice and a banana (Correct answer)
- White bread with cream cheese
- Apple sauce and white crackers
Correct answer: Orange juice and a banana
Oranges and bananas are high-potassium foods contraindicated in clients with chronic renal failure on potassium restriction.
Clients with CKD cannot adequately excrete potassium, risking hyperkalemia and dangerous cardiac dysrhythmias. Bananas (~422 mg potassium) and orange juice (~496 mg/8 oz) are both high-potassium. Low-potassium choices include white rice, white bread, apples, pears, cream cheese, and refined grains. Dietitian referral is essential in Canadian CKD management. Practical nurses reinforce dietary restrictions and assess meal trays.
Question 4: A client develops chills, fever, and back pain 20 minutes into a blood transfusion. What is the first nursing action?
- Slow the rate and notify the physician
- Stop the transfusion immediately and maintain IV access with normal saline (Correct answer)
- Give antipyretic and continue at the same rate
- Document and continue monitoring
Correct answer: Stop the transfusion immediately and maintain IV access with normal saline
Signs of transfusion reaction require immediately stopping the transfusion while maintaining IV access with normal saline.
Chills, fever, and back pain during transfusion suggest acute hemolytic reaction (life-threatening). Sequence: STOP transfusion immediately; keep IV open with normal saline (not the blood tubing); notify physician and charge nurse; monitor vital signs continuously; stay with client; return blood bag and tubing to blood bank with reaction form; obtain blood/urine samples as ordered. Canadian Blood Services standards require all reactions to be reported. Never restart or slow a transfusion when a reaction is suspected.
Question 5: A client with left-sided stroke has left hemiplegia and dysphagia. Which meal positioning is most appropriate?
- Semi-reclined at 30 degrees
- Upright at 90 degrees with head turned toward the weaker side (Correct answer)
- Left lateral position with head elevated
- Tilt head back to open the airway
Correct answer: Upright at 90 degrees with head turned toward the weaker side
Upright 90 degrees with head turned to the weak side closes that side of the pharynx, directing the food bolus to the stronger side.
For unilateral dysphagia post-stroke: sit fully upright at 90 degrees; turn head toward the affected (weaker) side to close that pyriform sinus and direct the food bolus to the stronger, functioning side; chin-tuck as directed by speech-language pathology; use thickened liquids if ordered; have suction available. Tilting the head back promotes aspiration. This is part of dysphagia management per Heart and Stroke Foundation of Canada guidelines.
Question 6: A family member is about to activate the PCA button for a sleeping client. What is the correct nursing response?
- Allow it since the family knows when the client needs pain relief
- Educate the family that only the client should activate the PCA and explain the safety reasons (Correct answer)
- Disconnect the PCA since the family is misusing it
- Notify the physician to discontinue the PCA
Correct answer: Educate the family that only the client should activate the PCA and explain the safety reasons
PCA by proxy bypasses the built-in safety mechanism where only an awake, alert client can press the button, risking respiratory depression.
PCA by proxy (family pressing the button for a sleeping/sedated client) eliminates the built-in safety feature — only a conscious client should press the button. If the client is asleep, their pain is controlled. PCA by proxy risks opioid-induced respiratory depression. The practical nurse must: educate the family about the danger; document the education; notify the charge nurse; assess the client's current sedation level. This is a critical safety issue in Canadian accreditation standards.
CPNRE Complex Care 2
A client post-abdominal surgery reports sudden severe abdominal pain with board-like rigidity.
What is the priority nursing action?