29. Review the scenario below: Which of the following action…
29. Review the scenario below: Which of the following actions would the nurse anticipate: Orders Labs Nurse Note IV 0.9% NACL @ 100 mL/ HR Vancomycin 500 mg/250 mL every 6 hours IVPB Rocephin 1 gram IV piggy back every 12 hours ibuprofen 400 mg by mouth every 6 hours as needed for pain Vital Signs Q 4 hours Diet as tolerated Wound care to LLE twice daily-cleanse with wound cleanse, pat dry, cover with sterile 4x4s and secure with Tegaderm. Foley to drainage bag Strict I&O Daily Weight Ambulate with assist Up in chair TID for meals CBC: WBC 15,700 RBC 3.7 Hgb 11.5 HCT 37.9 PLT 268,000 neutrophils 47% Lymphs 46% Monocytes 6% EOS 1% Basos 0 % CMP: BUN 24 mg/dL Creatinine 1.5 mg/dL Na+ 132 mmol/L K+ 3.3 mmol/L Chloride 96 mmol/L Calcium 8.9 mg/dL 0610: Client resting in bed, responds to verbal stimulus, alert and oriented to time, place and situation. IV site to LEFT forearm patent, infusing NS @ 100mL/hr via pump, without redness or edema at site. Denies complaints of tenderness. Dressing to Left lower leg dry/intact. Skin warm and dry. Extremities with 3+ cap refill, dorsalis pedis pulses palp and equal bilat. Abdomen soft, non-tender. Bowel sounds hyperactive x 4 quads. Last BM reported by patient this morning was watery, large amount with a foul odor. Complains of abdominal cramping and nausea. Oral cavity without redness/lesions. Foley intact, patent and draining clear, pink tinged urine. . Bladder non distended. requests antidiarrheal at this time. Will continue to monitor.