Question

10:00 el X Clinical Simulation 24... Mrs. Julia Davis is a 76 year old woman wia hiory CAD and froquent UTis. She is admitod to the modical surgical unil from the ER wi soB, lower abdoinl pain, chest pain lasting less than 3 minutes and nelieved with nitroglycerine. Her vital sigm are: HP 1709%, AR 106, R 28,T 1023 Provider's onders: Bodrest 022L via nasal cannula for fest 4 hrs, then every 4 hrs 17090, Tem102 peripheral IVNS 1000 ml at 50 ml Call MD for B CXR soday Collect urine for culture and sensitity Digosin & 125 mg daily, hold for HR 60 Tylenol 650 mg every 4 rs pre Tem10 Lasis 20 mg IVP now Ampicillin 250 mg INTB every On insertion of the catheser, the balloon canent be ened and the client complains of pain. BP is 190/100 afhe one hour. Client complains of chest pain. No urinc outut fo Whot asessments need to be made by the mus What is the priority for the nurse when the di arrives in the room What infoemation does the know to dilute ampicillin if it is supplied in a vial as a powder? Ilow fast can is be infused Over what period of time should the Lasix be administorod Can any of the tasks he delegated to UAPs? List nursing diagoses applicable to his clic Construct a concept map for this client Write a plan of care and inservestion necessary for this parient

Answer 1

# The assessments that need to be made by the nurse are:-

- vitals including temperature, respiratory rate ,blood pressure ,heart rate ,SPO2

- assess the patient for shortness of breath

- assess the pain status of the patient

- assess the placement of Foley's catheter

# The priority of the nurse when the client arrives the room is to assess the breathing status of the patient

# Ampicillin for Injection, USP, 1 g or 2 g, may also be given by direct Intravenous administration. Dissolve in 7.4 or 14.8 mL Sterile Water for Injection, USP, or Bacteriostatic Water for Injection, USP, respectively, and administer slowly over at least 10 to 15 minutes.

# Lasix injection is injected directly or into tubing of actively running IV over 1-2 minutes . Administer undiluted IV injection at the rate of 20 - 40 mg /min ; not to exceed 4mg/min for short term intermittent infusion . Use infusion solution within 24hours .