Question

5 I 7 8 9 You are caring for a 26-year-old who had a ruptured appendix with emergency appendectomy 2 days ago. The following data is given in report before assuming care: VITAL SIGNS ASSESSMENT COLLABORATIVE Temp 101.4F Pulse 108 Sinus tachycardia BP 148/76 Breath sounds decreased bilaterally Nonproductive cough Bowel sounds present X4, brown purulent drainage from wound drain O2 at 3L/min Gentamicin and ceftriaxone IV ABFS, CBC, BUN, electrolytes and glucose O2 Saturation 90% (98 % four hours ago) pending Gentamicin trough level ordered Alert and oriented X 3 Based on the data, what is the greatest concern? Underline your answer add rationale for choice. . Infection R/T pathogen exposure AEB purulent drainage Perfusion R/T decreased diastole AEB tacycardia 108 Oxygenation R/T hypoxia AEB 02 Sat 90 % Thermoregulation R/T increased metabolic rate AEB temp 101.4 The client's gentamicin is scheduled at 10:00 AM. When do you tell the laboratory to draw blood for the trough level? (Underline correct answer and give your rationale) 9 AM 9:45 AM 11:00 AM 1400 PM

Answer 1

Based on the data the greatest concern is

Perfusion related to decreased diastole as evidenced by tachycardia 108.

Because sinus tachycardia is the dangerous fatal condition.

When we are taking care of patient at emergency department priority should be as below.

ABC mnemonic

A- airway

B- Breathing

C- circulation.

Later remaining problems should be concerned.

Here the patient does not have any problems related to airway and breathing. So that the next priority is circulation.

Patient is having altered perfusion. So that it is greater concern.

Client's gentamicin is scheduled at 10.00AM. you have to ask the laboratory to draw blood at 11.00AM.