Brooke Gentry, Patient is a 34 y/o G5P4 who gave birth to a…

Brooke Gentry, Patient is a 34 y/o G5P4 who gave birth to a 9lb. 3 oz male infant following a 12-hour elective oxytocin induction of labor. She had an uncomplicated labor, epidural anesthesia and a rapid second stage, no episiotomy or perineal lacerations. Indwelling urinary catheter was removed prior to delivery. She is now one hour postpartum and is breastfeeding her baby. An IV of 1000 mL Lactated Ringers is infusing at KVO rate with an infusion of Lactated Ringers with oxytocin 20 Units infusing IVPB at 125 mL/hour. Upon entering her room, she tells you that she “feels wet”, and may have urinated on herself since she is still numb from the epidural and unable to move legs.  She is anxious, appears pale, and complains of feeling light-headed. Her husband is at her bedside. Assessment findings: Blood pooling under buttocks with several large clots; fundus boggy and slightly deviated to the right, 3 cm. above umbilicus; Vital signs: BP 90/60, P 110, R. 20, SAO2 98%, skin color pale, patient alert and oriented; unable to move legs, holding and breastfeeding baby.  In what order would you perform the following interventions: Set oxytocin rate to Bolus on IV pump as ordered by healthcare provider. Call for help using emergency call system. Assist mother to unlatch infant from breast and place infant in crib or hand to husband. Massage uterine fundus. Assess bladder status and need to perform straight catheter.

Arthur Harris is a 59-year-old African American male with a…

Arthur Harris is a 59-year-old African American male with a history of type 2 diabetes. He was directly admitted from his provider’s office with an infected sacral wound, which developed several months ago while on bed rest following an ankle sprain. He reports a history of depression, currently exacerbated by the death of his wife 6 months ago. Since admission, Arthur has received wound care, antibiotic therapy, and IV pain medications. He has also been receiving correction scale insulin coverage with meals, though his appetite has been poor and he has not been eating well.  Arthur Harris’ friend calls out from the room that Arthur is unresponsive. Arthur is lying supine in bed. His IV is pulled out and fluid is running into a puddle on the floor. What is your priority assessment?

Arthur Harris is a 59-year-old African American male with a…

Arthur Harris is a 59-year-old African American male with a history of type 2 diabetes. He was directly admitted from his provider’s office with an infected sacral wound, which developed several months ago while on bed rest following an ankle sprain. He reports a history of depression, currently exacerbated by the death of his wife 6 months ago. Since admission, Arthur has received wound care, antibiotic therapy, and IV pain medications. He has also been receiving correction scale insulin coverage with meals, though his appetite has been poor and he has not been eating well.  Arthur Harris’ friend calls out from the room that Arthur is unresponsive. Arthur is lying supine in bed. His IV is pulled out and fluid is running into a puddle on the floor. What is your priority assessment?

Andy Martin, 81 year old. Dx-Metastatic CA of Colon, Hx of d…

Andy Martin, 81 year old. Dx-Metastatic CA of Colon, Hx of diabetes. Palliative care. NKD Vital Signs: Temp 98.7 BP 114/67 P 115 R 20 SaO2 98% Neuro WNL alert and cooperative. Skin warm and dry. Blood glucose 185, 4 units of insulin sliding scale for coverage. ADA diet, intake 25% Demerol 25 mg SIVP for pain, reports pain 7/10 on pain scale. Patient and family upset regarding diagnosis. Select the appropriate nursing diagnosis for Mr. Martin. (Select all that apply)

Arthur Harris is a 59-year-old African American male with a…

Arthur Harris is a 59-year-old African American male with a history of type 2 diabetes. He was directly admitted from his provider’s office with an infected sacral wound, which developed several months ago while on bed rest following an ankle sprain. He reports a history of depression, currently exacerbated by the death of his wife 6 months ago. Since admission, Arthur has received wound care, antibiotic therapy, and IV pain medications. He has also been receiving correction scale insulin coverage with meals, though his appetite has been poor and he has not been eating well.  Arthur Harris’ friend calls out from the room that Arthur is unresponsive. Arthur is lying supine in bed. His IV is pulled out and fluid is running into a puddle on the floor. What is your priority assessment?