A nurse is caring for a client in the emergency department (…
A nurse is caring for a client in the emergency department (ED). Nurses’ note: 0800: Client brought to ED by ambulance from long-term care facility. According to report from long-term care facility RN, client is normally alert but awoke this am disoriented to time and place, febrile, and incontinent of foul-smelling urine. 0815: Provider at bedside, prescriptions received. Vital signs: 0800: Temperature 37.3° C (99.2° F) Pulse 102/min Respirations 20/min Blood pressure 130/82 mm Hg Oxygen Saturation 95% on room air Physical examination: 0830: Client disoriented to time and place. Agitated. Attempting to get out of bed. Sinus tachycardia. Lung sounds clear. Bowel sounds x 4 normoactive. Incontinent of urine. Plan: Admit for observation Fall precautions Begin broad-spectrum antibiotic Administer Acetaminophen (Tylenol) PO for temperature greater than 38° C (100.4° F) Complete blood count Straight catheterization to obtain a urine specimen for urinalysis and culture and sensitivity (C&S). The nurse should first address the client’s (1.__________), followed by the client’s (2.________). Complete the sentence above by selecting the answer best associated with the first priority followed by the best associated with the second priority. Answer choices with a #1 next to them indicate the options for first priority, and answer choices with a #2 next to them indicate the options for second priority. Only one answer with a #1 and one answer with a #2 should be selected.