HESI Peripheral Vascular Disease (PVD) with Amputation (med-
surg) Graded A+
Scenario Overview
- Client Name: Hans (identified by another homeless person).
- Situation: Hans is unable to provide identification due to unconsciousness and has no contact with
family. He requires immediate surgery to amputate his right leg above the knee.
Informed Consent
Since informed consent cannot be obtained, the nurse's priority action is:
- D. Prepare Hans for surgery and document that no family member is available.
In emergency situations, where immediate action is necessary to prevent further harm, the surgeon
can proceed without formal consent, and the nurse should prepare the client for surgery.
Preoperative Care: Personal Items
Hans is wearing a watch and a ring. The appropriate action for the nurse is:
- C. Assign two nurses to place the items in a bag and place them in the hospital safe.
This ensures the personal items are securely documented and stored, as there is no family member
present to take responsibility.
Purpose of the "Time Out"
When Hans arrives in the OR:
- D. So all members of the OR team participate in the positive identification of the client, ID correct site,
and ID planned procedure.
The "time out" is mandated by the Joint Commission to enhance client safety and confirm the correct
procedure is being performed.
Handling the Amputated Limb
After the surgery, the surgeon informs the operating room nurse that Hans does not have family or
representatives present. The nurse should:
- C. Ensure that the limb is sent to the incinerator so that it can be burned.
, Amputated limbs are disposed of according to hospital policies, generally involving destruction via
incineration for safety and hygiene reasons.
Special Cultural Requests
If the client has made cultural requests regarding the disposal or handling of the amputated limb:
- These requests must be discussed and arranged with the surgical team prior to the procedure to
ensure the client's cultural needs are respected.
Intensive Care Unit:
Hans in admitted to ICU with a right, above the knee amputation, a soft dressing with the residual limb,
an IV of Lactated RInger's at 125ml/hr and a Foley catheter.
The nurse hangs a new bag of IV fluids and checks the rate. The IV tubing delivers 15 drops/mL. How
many drops/min will the IV set deliver? ✔️(125ml/1hr) x (1hr/60min) x (15 drops/ 1mL)
=31 drops/min
Hans opens his eyes when his name is called and is able to answer simple questions. he is posting to his
right leg and saying "hurts real bad." The nurse assesses Hans' vital signs, which are stable, and observes
that the right residual limb dressing is dry and intact.
What action will the nurse implement to address Hans' right leg pain?
a. explain that the right leg was removed and there should not be any pain
b. notify the surgeon that Hans is having pain and pointing to the right leg
c. medicate Has with prescribed opioid analgesic immediately
d. instruct Hans in relaxation techniques to help decrease the pain ✔️c. medicate Has with prescribed
opioid analgesic immediately
surgical pain is expected in the immediate post-op period and warrants opioid analgesics
surg) Graded A+
Scenario Overview
- Client Name: Hans (identified by another homeless person).
- Situation: Hans is unable to provide identification due to unconsciousness and has no contact with
family. He requires immediate surgery to amputate his right leg above the knee.
Informed Consent
Since informed consent cannot be obtained, the nurse's priority action is:
- D. Prepare Hans for surgery and document that no family member is available.
In emergency situations, where immediate action is necessary to prevent further harm, the surgeon
can proceed without formal consent, and the nurse should prepare the client for surgery.
Preoperative Care: Personal Items
Hans is wearing a watch and a ring. The appropriate action for the nurse is:
- C. Assign two nurses to place the items in a bag and place them in the hospital safe.
This ensures the personal items are securely documented and stored, as there is no family member
present to take responsibility.
Purpose of the "Time Out"
When Hans arrives in the OR:
- D. So all members of the OR team participate in the positive identification of the client, ID correct site,
and ID planned procedure.
The "time out" is mandated by the Joint Commission to enhance client safety and confirm the correct
procedure is being performed.
Handling the Amputated Limb
After the surgery, the surgeon informs the operating room nurse that Hans does not have family or
representatives present. The nurse should:
- C. Ensure that the limb is sent to the incinerator so that it can be burned.
, Amputated limbs are disposed of according to hospital policies, generally involving destruction via
incineration for safety and hygiene reasons.
Special Cultural Requests
If the client has made cultural requests regarding the disposal or handling of the amputated limb:
- These requests must be discussed and arranged with the surgical team prior to the procedure to
ensure the client's cultural needs are respected.
Intensive Care Unit:
Hans in admitted to ICU with a right, above the knee amputation, a soft dressing with the residual limb,
an IV of Lactated RInger's at 125ml/hr and a Foley catheter.
The nurse hangs a new bag of IV fluids and checks the rate. The IV tubing delivers 15 drops/mL. How
many drops/min will the IV set deliver? ✔️(125ml/1hr) x (1hr/60min) x (15 drops/ 1mL)
=31 drops/min
Hans opens his eyes when his name is called and is able to answer simple questions. he is posting to his
right leg and saying "hurts real bad." The nurse assesses Hans' vital signs, which are stable, and observes
that the right residual limb dressing is dry and intact.
What action will the nurse implement to address Hans' right leg pain?
a. explain that the right leg was removed and there should not be any pain
b. notify the surgeon that Hans is having pain and pointing to the right leg
c. medicate Has with prescribed opioid analgesic immediately
d. instruct Hans in relaxation techniques to help decrease the pain ✔️c. medicate Has with prescribed
opioid analgesic immediately
surgical pain is expected in the immediate post-op period and warrants opioid analgesics
