NCLEX-RN Practice Test 9

Day 2, 2000: Alert and oriented × 4. Right ankle pain 4/10, relieved by oxycodone 5 mg PO at 1830. Says, "I just can't settle down tonight." Hands slightly tremulous when holding a cup. Splint intact; toes warm and pink.

Day 3, 0415: Bed alarm sounding; client found standing on the left leg at the bedside, pulling at the right leg splint. Returned to bed with the help of 2 staff members; no fall. Client is diaphoretic, with a coarse tremor of both hands. States, "There are bugs crawling all over the sheets — get them off me!" and keeps picking at the linens. Oriented to person only; believes he is at work. Pupils 6 mm, equal and briskly reactive. Lung sounds clear bilaterally. Right toes pink and warm, capillary refill less than 2 seconds; moves toes on request; splint intact and surgical dressing dry. No bowel movement since admission; bowel sounds hypoactive; abdomen soft and nondistended; no nausea. Peripheral IV in left forearm patent. Last oxycodone 5 mg PO given at 0200. CIWA-Ar score 24 at 0420. Provider paged.

Day 3, 0430: Client's wife returned the nurse's call. She reports that the client drinks "about a pint of vodka every day" and has for years, and that his last drink was the evening of the fall (Day 0 at about 1900).

History and Physical (Day 0, 2230). Client, age 56, admitted after falling down porch steps; closed right bimalleolar ankle fracture. Open reduction and internal fixation performed Day 1 at 0900 under general anesthesia; non-weight-bearing on the right leg. Past medical history: hypertension, gastroesophageal reflux disease. Home medications: lisinopril 10 mg PO daily, omeprazole 20 mg PO daily. Allergies: no known drug allergies. Social: warehouse supervisor; married; smokes 1 pack of cigarettes per day; reports drinking "2 or 3 beers on weekends"; denies drug use. No history of withdrawal seizures documented. Weight 84 kg. Admission blood alcohol level 186 mg/dL; client was conversing clearly and walking with assistance before the fracture was splinted.

Active orders (Day 1, post-operative): Oxycodone 5 mg PO every 4 hours PRN moderate pain (4–6/10). Acetaminophen 1,000 mg PO every 8 hours. Enoxaparin 40 mg subcutaneously daily. Lisinopril 10 mg PO daily. Omeprazole 20 mg PO daily. Lactated Ringer's at 75 mL/h. Elevate right leg; ice to right ankle 20 minutes every 2 hours while awake. Neurovascular checks right foot every 4 hours. Non-weight-bearing right leg; physical therapy for gait training with walker. Fall precautions; bed alarm. Regular diet.