Question

Choose and explain the WRONG nursing intervention for the case scenario below and then rank the rest in order of importance:

Today you start your shift with Ryan; a 25-year-old admitted through the Emergency Room after a motor vehicle accident with rollover resulting in a fractured right femur, multiple rib fractures, sternal bruises, and multiple abrasions. He is two hours post-op from an open reduction internal fixation of the right femur and appears alert and oriented. When you enter the room his first statement is, “Can someone please get me a cigarette or a patch; I have not had a smoke since yesterday morning!”

Assessment Data:

• The client is sitting up in bed with anti-embolism stockings on the left leg only.
• Dressings to multiple abrasions appear dry.
• Urine in Foley Bag amber colored and urinary output in the past 2 hours 40cc
• Pain reported as 8 on a scale of 10 with a goal of 5

Vital signs:

• BP 130/80
• Heart Rate 92
• O2 Sats 94% on 4L Nasal Cannula

Blood Gases:

• pH 7.32
• PaCO2 53 mmHg
• HCO3 22mmol/L
• Pao2 84mm Hg

Physician’s Orders:

• Bed Rest Only
• Clear Liquid Diet
• Oxygen to maintain Spo2 of 92% or greater
• ABGs repeated every 4 hours
• Discontinue PCA and consult pain management
• Administer tetanus and flu immunizations before discharge

Nursing Interventions:

1. Administer 2mg Morphine IV now for breakthrough pain
2. Apply anti-emoblism stockings bilaterally
3. Call the physician to get an order for Nicotine Patch and report decreased urinary output with amber urine
4. Input consult for pain management into the electronic order system
5. Decrease O2 to 2L Nasal Cannula and continue Sp02 monitoring
6. Administer tetanus immunization

Answer 1

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