Jonny Deadfoot

What is the priority nursing intervention for Mr. Jonny Deadfoot’s care?

• a) Provide nonpharmacologic pain relief, such as repositioning and relaxation techniques.

• b) Perform aseptic dressing changes and closely monitor for signs of spreading infection.

• c) Encourage ambulation to aid circulation and reduce pressure injury risk.

• d) Administer stool softeners to ease constipation related to opioid use.

The patient’s white blood cell count (WBC) is 11.1 (with previous 12.4) and his temperature is 37.6°C. What is the most appropriate nursing action?

• a) Reduce antibiotic dosage due to improving labs

• b) Monitor for further deterioration and continued signs of infection

• c) Stop antibiotic therapy immediately

• d) Apply a warm compress to ease redness

The patient’s diabetic foot ulcers and necrosis contribute to his increase in infection risk.

• True

• False

What is a critical side effect related to oxycodone administration that should be closely monitored by the nurse?

• a) Diarrhea

• b) Elevated temperature

• c) Respiratory depression

• d) Increased activity level

Elevating the patient’s limbs can aid in reducing edema and pressure injury risk.

• True

• False

The patient’s Braden Scale score assesses for:

• a) Fluid intake adequacy

• b) Ability to perform activities of daily living

• c) Oxygenation status

• d) Risk for developing pressure ulcers

While Mr. Jonny is on Meropenem and shows redness, peeling skin, and elevated WBCs, what should the nurse closely monitor for a potential complication?

• a) Serum creatinine and urine output

• b) Serum glucose drops

• c) Serum sodium level

• d) Serum calcium level

Mr. Jonny Deadfoot’s diabetic foot ulcers are necrotic and show peeling skin and redness. His white blood cell count is 11.1, and his temperature is 37.6°C.
He is at risk for developing sepsis.
What is the earliest and most reliable indicator that sepsis may be progressing toward shock?

• a) Rising white blood cell count

•  b) Low grade fever (37.6°C)
  

• c) Peripheral edema (+3)

• d) Decreased urine output (< 0.5 mL/kg/hr)